- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $38.90 / $38.90
| Facility | | $38.90 | $38.90 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.88 / $16.98 / $67.61
| Professional | | $12.88 | $16.98 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.75 / $11.75 / $23.44
| Professional | | $11.75 | $11.75 | $23.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $74.13
| Facility | | $74.13 | $74.13 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $20.89 / $20.89
| Professional | | $20.89 | $20.89 | $20.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $23.44 / $23.44 / $24.55
| Facility | | $23.44 | $23.44 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.39 / $22.39 / $22.39
| Professional | | $22.39 | $22.39 | $22.39 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $257.04
| Professional | | $208.93 | $208.93 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $18.62 / $29.51 / $46.77
| Facility | | $18.62 | $29.51 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.88 / $33.11 / $44.67
| Professional | | $12.88 | $33.11 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $17.38 / $28.84 / $44.67
| Facility | | $17.38 | $28.84 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.39 / $22.39 / $22.39
| Professional | | $22.39 | $22.39 | $22.39 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $26.30 / $26.30
| Facility | | $26.30 | $26.30 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $19.95 / $52.48
| Professional | | $15.85 | $19.95 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.30 / $12.30 / $23.99
| Professional | | $12.30 | $12.30 | $23.99 |