- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $57.54
| Facility | | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $43.65 / $57.54
| Professional | | $30.20 | $43.65 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $50.12 / $53.70
| Professional | | $50.12 | $50.12 | $53.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9.55 / $56.23 / $56.23
| Facility | | $9.55 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $40.74 / $58.88
| Professional | | $40.74 | $40.74 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $33.11 / $50.12
| Professional | | $30.90 | $33.11 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $57.54 / $97.72
| Facility | | $28.18 | $57.54 | $97.72 |
- 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
- $22.39 / $33.11 / $53.70
| Facility | | $22.39 | $33.11 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $33.11 / $50.12
| Professional | | $25.70 | $33.11 | $50.12 |
- 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
- $501.19 / $501.19 / $549.54
| Professional | | $501.19 | $501.19 | $549.54 |