- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $47.86 / $47.86
| Facility | | $47.86 | $47.86 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $47.86 / $323.59
| Professional | | $20.89 | $47.86 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $74.13 / $74.13
| Professional | | $66.07 | $74.13 | $74.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $43.65 / $85.11
| Facility | | $43.65 | $43.65 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $89.13 / $131.83
| Professional | | $43.65 | $89.13 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $83.18 / $354.81
| Facility | | $47.86 | $83.18 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $44.67 / $75.86
| Professional | | $25.12 | $44.67 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $204.17
| Professional | | $83.18 | $83.18 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Facility | | $85.11 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $190.55 / $204.17
| Professional | | $104.71 | $190.55 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $52.48 / $79.43
| Facility | | $44.67 | $52.48 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $27.54 / $38.02 / $58.88
| Professional | | $27.54 | $38.02 | $58.88 |