- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $58.88
| Facility | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $40.74 / $58.88
| Professional | | $29.51 | $40.74 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $52.48
| Professional | | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $42.66 / $42.66
| Facility | | $30.20 | $42.66 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $52.48
| Professional | | $30.90 | $30.90 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $45.71 / $45.71
| Professional | | $42.66 | $45.71 | $45.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $60.26 / $102.33
| Facility | | $28.84 | $60.26 | $102.33 |
- 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
- $25.70 / $33.88 / $56.23
| Facility | | $25.70 | $33.88 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $33.88 / $51.29
| Professional | | $26.30 | $33.88 | $51.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $371.54 / $371.54
| Facility | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |