- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.01 / $5.01 / $5.01
| Facility | | $5.01 | $5.01 | $5.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.01 / $8.91 / $12.02
| Professional | | $5.01 | $8.91 | $12.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $69.18 / $173.78
| Facility | | $54.95 | $69.18 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.01 / $9.12 / $14.13
| Professional | | $5.01 | $9.12 | $14.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $36.31 / $63.10
| Professional | | $23.99 | $36.31 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.23 / $10.23 / $10.23
| Professional | | $10.23 | $10.23 | $10.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $33.88 / $154.88
| Professional | | $30.20 | $33.88 | $154.88 |
- 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
- $100.00 / $102.33 / $102.33
| Professional | | $100.00 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $15.85 / $15.85
| Professional | | $15.85 | $15.85 | $15.85 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $70.79
| Professional | | $54.95 | $54.95 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $8.13 / $16.22 / $25.70
| Facility | | $8.13 | $16.22 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.23 / $10.23 / $10.23
| Professional | | $10.23 | $10.23 | $10.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.25 / $7.76 / $14.79
| Professional | | $5.25 | $7.76 | $14.79 |