- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $2.00 / $2.04
| Facility | | $2.00 | $2.00 | $2.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $2.00 / $2.04
| Professional | | $2.00 | $2.00 | $2.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $61.66 / $3,162.28
| Facility | | $61.66 | $61.66 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $61.66 / $1,698.24
| Professional | | $61.66 | $61.66 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Facility | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Facility | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Professional | | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Facility | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $109.65 / $109.65
| Professional | | $85.11 | $109.65 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.04 / $2.04 / $4.27
| Facility | | $2.04 | $2.04 | $4.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $2.00 / $2.04
| Professional | | $2.00 | $2.00 | $2.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $50.12
| Professional | | $30.20 | $30.20 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.04 / $2.04 / $4.47
| Facility | | $2.04 | $2.04 | $4.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Professional | | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $97.72
| Professional | | $97.72 | $97.72 | $97.72 |