- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $72.44
| Facility | | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $32.36 / $44.67
| Professional | | $25.70 | $32.36 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.01 / $5.50 / $23.99
| Professional | | $5.01 | $5.50 | $23.99 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Facility | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.44 / $23.44 / $23.44
| Professional | | $23.44 | $23.44 | $23.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $208.93
| Facility | | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $331.13 / $331.13
| Professional | | $218.78 | $331.13 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $41.69 / $64.57
| Facility | | $29.51 | $41.69 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $34.67 / $66.07
| Professional | | $25.70 | $34.67 | $66.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $39.81 / $64.57
| Facility | | $28.84 | $39.81 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.44 / $23.44 / $23.44
| Professional | | $23.44 | $23.44 | $23.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16.22 / $16.22 / $16.22
| Facility | | $16.22 | $16.22 | $16.22 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.59 / $18.62 / $36.31
| Professional | | $12.59 | $18.62 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $22.91 / $43.65
| Professional | | $16.98 | $22.91 | $43.65 |