- 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 / $21.88
| Professional | | $1.00 | $1.00 | $21.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.12 / $2.69 / $7.76
| Facility | | $1.12 | $2.69 | $7.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.12 / $1.12 / $1.12
| Professional | | $1.12 | $1.12 | $1.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $89.13
| Facility | | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.71 / $11.22 / $11.22
| Professional | | $8.71 | $11.22 | $11.22 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.85 / $1.51 / $3.98
| Facility | | $0.85 | $1.51 | $3.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $1.00 / $1.32
| Professional | | $1.00 | $1.00 | $1.32 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.91 / $1.58 / $9.77
| Facility | | $0.91 | $1.58 | $9.77 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.12 / $1.12 / $1.12
| Professional | | $1.12 | $1.12 | $1.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.58 / $2.14 / $7.59
| Facility | | $1.58 | $2.14 | $7.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $234.42
| Professional | | $234.42 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $234.42
| Professional | | $234.42 | $234.42 | $234.42 |