- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $42.66 / $42.66
| Facility | | $42.66 | $42.66 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $42.66 / $398.11
| Professional | | $21.88 | $42.66 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $66.07 / $67.61
| Professional | | $60.26 | $66.07 | $67.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $42.66 / $77.62
| Facility | | $42.66 | $42.66 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $79.43 / $131.83
| Professional | | $42.66 | $79.43 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $77.62 / $363.08
| Facility | | $43.65 | $77.62 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.91 / $33.88 / $67.61
| Professional | | $22.91 | $33.88 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $186.21
| Professional | | $75.86 | $75.86 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $77.62
| Facility | | $77.62 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $169.82 / $186.21
| Professional | | $95.50 | $169.82 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $40.74 / $79.43
| Facility | | $26.30 | $40.74 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $24.55 / $33.88 / $53.70
| Professional | | $24.55 | $33.88 | $53.70 |