- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $33.88 / $33.88
| Facility | | $33.88 | $33.88 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.05 / $25.12 / $33.88
| Professional | | $19.05 | $25.12 | $33.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $41.69 / $41.69
| Facility | | $41.69 | $41.69 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $32.36
| Professional | | $30.20 | $30.20 | $32.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.50 / $19.50 / $19.95
| Facility | | $19.50 | $19.50 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.60 / $16.60 / $20.89
| Professional | | $16.60 | $16.60 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.60 / $17.78 / $28.18
| Professional | | $16.60 | $17.78 | $28.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $17.38 / $34.67 / $57.54
| Facility | | $17.38 | $34.67 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $11.75 / $15.85 / $28.18
| Facility | | $11.75 | $15.85 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.13 / $19.50 / $28.84
| Professional | | $14.13 | $19.50 | $28.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $181.97
| Facility | | $181.97 | $181.97 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $295.12
| Professional | | $199.53 | $199.53 | $295.12 |