- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $3.98 / $3.98
| Facility | | $1.00 | $3.98 | $3.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $1.00 / $1.05
| Professional | | $1.00 | $1.00 | $1.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $245.47 / $489.78
| Facility | | $109.65 | $245.47 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Professional | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $42.66 / $42.66
| Professional | | $42.66 | $42.66 | $42.66 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $1.20 / $3.98
| Facility | | $1.00 | $1.20 | $3.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $1.00 / $1.10
| Professional | | $1.00 | $1.00 | $1.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $44.67
| Professional | | $30.20 | $30.20 | $44.67 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.91 / $1.07 / $2.29
| Facility | | $0.91 | $1.07 | $2.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $87.10 / $109.65
| Facility | | $66.07 | $87.10 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $66.07 / $109.65
| Professional | | $54.95 | $66.07 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Professional | | $109.65 | $109.65 | $109.65 |