- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $40.74 / $40.74
| Facility | | $40.74 | $40.74 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $35.48 / $51.29
| Professional | | $25.12 | $35.48 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $35.48
| Professional | | $30.90 | $30.90 | $35.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $81.28 / $81.28
| Facility | | $63.10 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $46.77 / $48.98
| Professional | | $46.77 | $46.77 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $30.90
| Professional | | $30.90 | $30.90 | $30.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $48.98 / $85.11
| Facility | | $30.90 | $48.98 | $85.11 |
- 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
- $24.55 / $46.77 / $61.66
| Facility | | $24.55 | $46.77 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $30.20 / $43.65
| Professional | | $21.38 | $30.20 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $281.84 / $281.84
| Facility | | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $281.84 / $436.52
| Professional | | $281.84 | $281.84 | $436.52 |