- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $56.23
| Facility | | $56.23 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $316.23 / $316.23
| Professional | | $194.98 | $316.23 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.37 / $5.37 / $8.13
| Professional | | $5.37 | $5.37 | $8.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $33.88 / $53.70
| Facility | | $28.84 | $33.88 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $13.18 / $16.60 / $19.95
| Professional | | $13.18 | $16.60 | $19.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9.55 / $9.55 / $11.75
| Facility | | $9.55 | $9.55 | $11.75 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9.55 / $9.55 / $177.83
| Facility | | $9.55 | $9.55 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Professional | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $54.95 / $85.11
| Professional | | $50.12 | $54.95 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $28.18 / $28.18
| Professional | | $28.18 | $28.18 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $43.65 / $43.65
| Professional | | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $50.12 / $50.12
| Facility | | $50.12 | $50.12 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $13.49 / $13.49 / $13.49
| Professional | | $13.49 | $13.49 | $13.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $13.49 / $13.49 / $13.49
| Professional | | $13.49 | $13.49 | $13.49 |