- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $61.66 / $61.66
| Facility | | $61.66 | $61.66 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $46.77 / $61.66
| Professional | | $30.20 | $46.77 | $61.66 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $69.18
| Facility | | $57.54 | $57.54 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $58.88
| Professional | | $53.70 | $53.70 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $43.65 / $43.65
| Facility | | $30.90 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $31.62 / $54.95
| Professional | | $31.62 | $31.62 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $38.02 / $46.77
| Professional | | $34.67 | $38.02 | $46.77 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $61.66 / $104.71
| Facility | | $28.84 | $61.66 | $104.71 |
- 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
- $26.30 / $34.67 / $57.54
| Facility | | $26.30 | $34.67 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.92 / $34.67 / $52.48
| Professional | | $26.92 | $34.67 | $52.48 |
- 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
- $457.09 / $457.09 / $562.34
| Professional | | $457.09 | $457.09 | $562.34 |