- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $44.67 / $44.67
| Facility | | $44.67 | $44.67 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $37.15 / $44.67
| Professional | | $25.70 | $37.15 | $44.67 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $70.79
| Facility | | $54.95 | $70.79 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $39.81 / $42.66
| Professional | | $39.81 | $39.81 | $42.66 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $34.67 / $35.48
| Facility | | $34.67 | $34.67 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $29.51 / $34.67
| Professional | | $21.88 | $29.51 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $26.30 / $37.15
| Professional | | $23.99 | $26.30 | $37.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $22.91 / $45.71 / $75.86
| Facility | | $22.91 | $45.71 | $75.86 |
- 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
- $16.60 / $20.42 / $33.88
| Facility | | $16.60 | $20.42 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.62 / $25.70 / $37.15
| Professional | | $18.62 | $25.70 | $37.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $389.05
| Professional | | $263.03 | $263.03 | $389.05 |