- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $37.15 / $37.15
| Facility | | $37.15 | $37.15 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $37.15 / $37.15
| Professional | | $20.89 | $37.15 | $37.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $104.71 / $104.71
| Facility | | $57.54 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $57.54 / $77.62
| Professional | | $45.71 | $57.54 | $77.62 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $37.15 / $229.09
| Facility | | $37.15 | $37.15 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $70.79 / $109.65
| Professional | | $37.15 | $70.79 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $17.78 / $41.69 / $67.61
| Facility | | $17.78 | $41.69 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $37.15 / $37.15
| Professional | | $37.15 | $37.15 | $37.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $17.78 / $64.57 / $263.03
| Facility | | $17.78 | $64.57 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.92 / $32.36 / $52.48
| Professional | | $26.92 | $32.36 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.62 / $50.12 / $64.57
| Professional | | $18.62 | $50.12 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $27.54 / $53.70 / $97.72
| Professional | | $27.54 | $53.70 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $7.59 / $11.75 / $15.85
| Professional | | $7.59 | $11.75 | $15.85 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $114.82 / $263.03
| Facility | | $37.15 | $114.82 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $37.15 / $44.67
| Professional | | $30.90 | $37.15 | $44.67 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.51 / $20.89 / $42.66
| Facility | | $2.51 | $20.89 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $30.20 / $57.54
| Professional | | $21.38 | $30.20 | $57.54 |