- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $25.12 / $25.12
| Facility | | $25.12 | $25.12 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $21.88 / $30.20
| Professional | | $15.85 | $21.88 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $33.88 / $44.67
| Professional | | $33.88 | $33.88 | $44.67 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $134.90 / $257.04
| Facility | | $58.88 | $134.90 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $44.67 / $46.77
| Professional | | $44.67 | $44.67 | $46.77 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $24.55 / $24.55 / $24.55
| Facility | | $24.55 | $24.55 | $24.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $30.20 / $44.67
| Professional | | $21.88 | $30.20 | $44.67 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $85.11 / $95.50
| Facility | | $25.12 | $85.11 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $34.67 / $54.95
| Professional | | $21.88 | $34.67 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $30.20 / $40.74
| Professional | | $21.88 | $30.20 | $40.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.80 / $37.15 / $48.98
| Facility | | $13.80 | $37.15 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.14 / $21.38 / $32.36
| Professional | | $15.14 | $21.38 | $32.36 |