- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $64.57 / $165.96
| Facility | | $60.26 | $64.57 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $61.66 / $72.44
| Professional | | $57.54 | $61.66 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $120.23 / $131.83
| Facility | | $81.28 | $120.23 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $69.18 / $75.86
| Professional | | $61.66 | $69.18 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $100.00 / $144.54
| Facility | | $72.44 | $100.00 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $61.66 / $72.44
| Professional | | $61.66 | $61.66 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $45.71 / $45.71
| Professional | | $45.71 | $45.71 | $45.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $64.57 / $102.33
| Facility | | $57.54 | $64.57 | $102.33 |
- 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
- $61.66 / $102.33 / $114.82
| Facility | | $61.66 | $102.33 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $64.57 / $67.61
| Professional | | $60.26 | $64.57 | $67.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $331.13
| Facility | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $2,630.27 / $2,630.27
| Professional | | $2,630.27 | $2,630.27 | $2,630.27 |