- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $870.96 / $2,570.40
| Facility | | $288.40 | $870.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $1.00 / $1.00
| Professional | | $1.00 | $1.00 | $1.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.83 / $2.14 / $4.17
| Facility | | $0.83 | $2.14 | $4.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.41 / $0.41 / $0.41
| Professional | | $0.41 | $0.41 | $0.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.30 / $0.62 / $1.70
| Facility | | $0.30 | $0.62 | $1.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.25 / $0.25 / $0.25
| Professional | | $0.25 | $0.25 | $0.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $100.00 / $100.00
| Facility | | $85.11 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.25 / $1.00 / $1,737.80
| Facility | | $0.25 | $1.00 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.25 / $0.25 / $1.00
| Professional | | $0.25 | $0.25 | $1.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.25 / $0.25 / $0.28
| Professional | | $0.25 | $0.25 | $0.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.25 / $0.37 / $0.79
| Facility | | $0.25 | $0.37 | $0.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.25 / $0.25 / $0.25
| Professional | | $0.25 | $0.25 | $0.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.25 / $0.37 / $0.62
| Facility | | $0.25 | $0.37 | $0.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.25 / $0.28 / $0.39
| Professional | | $0.25 | $0.28 | $0.39 |