- 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
- $37.15 / $52.48 / $77.62
| Professional | | $37.15 | $52.48 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $72.44
| Professional | | $67.61 | $67.61 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $14.45 / $50.12 / $50.12
| Facility | | $14.45 | $50.12 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $36.31 / $52.48
| Professional | | $36.31 | $36.31 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $44.67 / $57.54
| Professional | | $41.69 | $44.67 | $57.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $77.62 / $128.82
| Facility | | $28.18 | $77.62 | $128.82 |
- 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
- $26.92 / $39.81 / $72.44
| Facility | | $26.92 | $39.81 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $44.67 / $63.10
| Professional | | $33.11 | $44.67 | $63.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $426.58
| Facility | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $457.09 / $645.65
| Professional | | $457.09 | $457.09 | $645.65 |