- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $43.65 / $43.65
| Facility | | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.20 / $43.65 / $331.13
| Professional | | $18.20 | $43.65 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $67.61 / $67.61
| Professional | | $61.66 | $67.61 | $67.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $36.31 / $77.62
| Facility | | $36.31 | $36.31 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $75.86 / $117.49
| Professional | | $36.31 | $75.86 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $75.86 / $309.03
| Facility | | $40.74 | $75.86 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.91 / $38.02 / $69.18
| Professional | | $22.91 | $38.02 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $186.21
| Professional | | $75.86 | $75.86 | $186.21 |
- 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
- $95.50 / $173.78 / $186.21
| Professional | | $95.50 | $173.78 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $44.67 / $66.07
| Facility | | $38.02 | $44.67 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $34.67 / $54.95
| Professional | | $25.12 | $34.67 | $54.95 |