- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.49 / $15.49 / $15.49
| Professional | | $15.49 | $15.49 | $15.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.01 / $5.01 / $12.30
| Professional | | $5.01 | $5.01 | $12.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.20 / $32.36 / $46.77
| Professional | | $18.20 | $32.36 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.30 / $25.70 / $36.31
| Professional | | $12.30 | $25.70 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $50.12 / $64.57
| Professional | | $44.67 | $50.12 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $47.86 / $47.86
| Facility | | $39.81 | $47.86 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $47.86 / $47.86
| Professional | | $47.86 | $47.86 | $47.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $20.42 / $20.42 / $20.42
| Facility | | $20.42 | $20.42 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.42 / $20.42 / $60.26
| Professional | | $20.42 | $20.42 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $32.36
| Facility | | $32.36 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.20 / $29.51 / $43.65
| Professional | | $18.20 | $29.51 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9.55 / $13.49 / $23.99
| Facility | | $9.55 | $13.49 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.00 / $12.59 / $28.18
| Professional | | $10.00 | $12.59 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.30 / $12.30 / $16.60
| Professional | | $12.30 | $12.30 | $16.60 |