- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $25.70 / $25.70
| Facility | | $25.70 | $25.70 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.96 / $25.70 / $173.78
| Professional | | $10.96 | $25.70 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $39.81 / $39.81
| Professional | | $36.31 | $39.81 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $22.91 / $22.91 / $45.71
| Facility | | $22.91 | $22.91 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.91 / $47.86 / $70.79
| Professional | | $22.91 | $47.86 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $44.67 / $190.55
| Facility | | $26.30 | $44.67 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $13.80 / $20.42 / $40.74
| Professional | | $13.80 | $20.42 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $45.71 / $109.65
| Professional | | $44.67 | $45.71 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $45.71 / $45.71
| Facility | | $45.71 | $45.71 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $102.33 / $109.65
| Professional | | $57.54 | $102.33 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $14.13 / $21.88 / $42.66
| Facility | | $14.13 | $21.88 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.79 / $20.42 / $32.36
| Professional | | $14.79 | $20.42 | $32.36 |