- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Facility | | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $77.62 / $93.33
| Professional | | $53.70 | $77.62 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $147.91 / $147.91
| Facility | | $107.15 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $89.13
| Professional | | $83.18 | $83.18 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $44.67 / $79.43
| Professional | | $44.67 | $44.67 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $53.70 / $77.62
| Professional | | $50.12 | $53.70 | $77.62 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $97.72 / $162.18
| Facility | | $46.77 | $97.72 | $162.18 |
- 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
- $31.62 / $45.71 / $72.44
| Facility | | $31.62 | $45.71 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $53.70 / $77.62
| Professional | | $38.02 | $53.70 | $77.62 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $812.83
| Professional | | $549.54 | $549.54 | $812.83 |