- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $53.70
| Facility | | $53.70 | $53.70 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $52.48 / $57.54
| Professional | | $30.90 | $52.48 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $56.23
| Professional | | $56.23 | $56.23 | $56.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $45.71 / $45.71
| Facility | | $32.36 | $45.71 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $33.11 / $56.23
| Professional | | $33.11 | $33.11 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $45.71 / $48.98
| Professional | | $42.66 | $45.71 | $48.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $61.66 / $107.15
| Facility | | $31.62 | $61.66 | $107.15 |
- 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
- $35.48 / $54.95 / $60.26
| Facility | | $35.48 | $54.95 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $36.31 / $56.23
| Professional | | $30.20 | $36.31 | $56.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $398.11
| Facility | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $588.84 / $741.31
| Professional | | $588.84 | $588.84 | $741.31 |