- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $23.99 / $30.20
| Professional | | $16.98 | $23.99 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $46.77 / $46.77
| Facility | | $33.88 | $46.77 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $26.30 / $28.18
| Professional | | $26.30 | $26.30 | $28.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $20.89 / $21.88
| Facility | | $20.89 | $20.89 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $17.38 / $17.38 / $24.55
| Professional | | $17.38 | $17.38 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $17.38 / $24.55
| Professional | | $15.85 | $17.38 | $24.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $15.14 / $30.20 / $50.12
| Facility | | $15.14 | $30.20 | $50.12 |
- 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
- $10.96 / $13.49 / $21.88
| Facility | | $10.96 | $13.49 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.02 / $16.98 / $24.55
| Professional | | $12.02 | $16.98 | $24.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Facility | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $257.04
| Professional | | $173.78 | $173.78 | $257.04 |