- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $53.70
| Facility | | $53.70 | $53.70 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $53.70 / $53.70
| Professional | | $30.90 | $53.70 | $53.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $154.88 / $154.88
| Facility | | $85.11 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $85.11 / $114.82
| Professional | | $67.61 | $85.11 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $57.54 / $338.84
| Facility | | $53.70 | $57.54 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $102.33 / $162.18
| Professional | | $53.70 | $102.33 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $66.07 / $97.72
| Facility | | $51.29 | $66.07 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $54.95
| Professional | | $54.95 | $54.95 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $95.50 / $389.05
| Facility | | $51.29 | $95.50 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $47.86 / $77.62
| Professional | | $39.81 | $47.86 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $58.88 / $89.13
| Professional | | $50.12 | $58.88 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $79.43 / $144.54
| Professional | | $40.74 | $79.43 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.22 / $19.05 / $26.30
| Professional | | $11.22 | $19.05 | $26.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $165.96 / $389.05
| Facility | | $53.70 | $165.96 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $53.70 / $64.57
| Professional | | $45.71 | $53.70 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.80 / $30.90 / $63.10
| Facility | | $3.80 | $30.90 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $45.71 / $85.11
| Professional | | $32.36 | $45.71 | $85.11 |