- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $30.90
| Facility | | $30.90 | $30.90 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $39.81 / $87.10
| Professional | | $21.88 | $39.81 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $24.55 / $28.18 / $52.48
| Professional | | $24.55 | $28.18 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $70.79
| Facility | | $58.88 | $58.88 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $28.18 / $29.51
| Professional | | $28.18 | $28.18 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.14 / $15.14 / $15.14
| Professional | | $15.14 | $15.14 | $15.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $24.55 / $37.15 / $83.18
| Facility | | $24.55 | $37.15 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.00 / $10.00 / $64.57
| Professional | | $10.00 | $10.00 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $35.48 / $37.15
| Professional | | $0.60 | $35.48 | $37.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.80 / $14.79 / $37.15
| Facility | | $13.80 | $14.79 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.88 / $17.38 / $26.30
| Professional | | $12.88 | $17.38 | $26.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $186.21 / $199.53
| Facility | | $186.21 | $186.21 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $478.63 / $478.63
| Professional | | $275.42 | $478.63 | $478.63 |