- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $2.00 / $2.00
| Facility | | $2.00 | $2.00 | $2.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $2.00 / $15.14
| Professional | | $2.00 | $2.00 | $15.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12.30 / $125.89 / $125.89
| Facility | | $12.30 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $141.25
| Professional | | $125.89 | $125.89 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $169.82 / $562.34
| Facility | | $50.12 | $169.82 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $17.78 / $25.70 / $588.84
| Facility | | $17.78 | $25.70 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $17.78 / $20.42 / $25.70
| Professional | | $17.78 | $20.42 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $50.12 / $75.86
| Professional | | $30.20 | $50.12 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.45 / $2.51 / $5.13
| Facility | | $2.45 | $2.51 | $5.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.72 / $11.22 / $14.79
| Facility | | $3.72 | $11.22 | $14.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.02 / $3.72 / $3.72
| Professional | | $3.02 | $3.72 | $3.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $11.22 / $12.30 / $125.89
| Facility | | $11.22 | $12.30 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $125.89 / $141.25
| Professional | | $123.03 | $125.89 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9.12 / $102.33 / $102.33
| Facility | | $9.12 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $9.12 / $125.89 / $125.89
| Professional | | $9.12 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $154.88 / $295.12
| Professional | | $134.90 | $154.88 | $295.12 |