- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $37.15 / $37.15
| Facility | | $37.15 | $37.15 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.20 / $24.55 / $37.15
| Professional | | $18.20 | $24.55 | $37.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $35.48 / $35.48 / $42.66
| Facility | | $35.48 | $35.48 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $33.11 / $35.48
| Professional | | $33.11 | $33.11 | $35.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10.72 / $26.92 / $26.92
| Facility | | $10.72 | $26.92 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.50 / $19.50 / $29.51
| Professional | | $19.50 | $19.50 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $21.38 / $28.18
| Professional | | $19.95 | $21.38 | $28.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $38.02 / $63.10
| Facility | | $16.98 | $38.02 | $63.10 |
- 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
- $12.88 / $19.05 / $35.48
| Facility | | $12.88 | $19.05 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $21.38 / $30.20
| Professional | | $15.85 | $21.38 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $316.23
| Professional | | $218.78 | $218.78 | $316.23 |