- 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
- $15.14 / $37.15 / $288.40
| Professional | | $15.14 | $37.15 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $56.23 / $56.23
| Professional | | $51.29 | $56.23 | $56.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $64.57
| Facility | | $30.90 | $30.90 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $75.86 / $97.72
| Professional | | $30.90 | $75.86 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $64.57 / $263.03
| Facility | | $37.15 | $64.57 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.50 / $28.84 / $58.88
| Professional | | $19.50 | $28.84 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $154.88
| Professional | | $64.57 | $64.57 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $144.54 / $154.88
| Professional | | $81.28 | $144.54 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.05 / $29.51 / $57.54
| Facility | | $19.05 | $29.51 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.42 / $28.84 / $43.65
| Professional | | $20.42 | $28.84 | $43.65 |