- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $57.54
| Facility | | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $38.02 / $57.54
| Professional | | $28.84 | $38.02 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $63.10
| Professional | | $58.88 | $58.88 | $63.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $37.15 / $47.86
| Facility | | $34.67 | $37.15 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.92 / $26.92 / $47.86
| Professional | | $26.92 | $26.92 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $39.81 / $39.81
| Professional | | $37.15 | $39.81 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $57.54 / $102.33
| Facility | | $25.70 | $57.54 | $102.33 |
- 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
- $28.84 / $44.67 / $63.10
| Facility | | $28.84 | $44.67 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $38.90 / $54.95
| Professional | | $29.51 | $38.90 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $331.13
| Facility | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $407.38 / $446.68
| Professional | | $407.38 | $407.38 | $446.68 |