- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $72.44
| Facility | | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $35.48 / $72.44 / $104.71
| Professional | | $35.48 | $72.44 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $151.36 / $162.18
| Facility | | $87.10 | $151.36 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $114.82 / $125.89
| Professional | | $109.65 | $114.82 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $81.28
| Facility | | $56.23 | $56.23 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $56.23 / $67.61
| Professional | | $47.86 | $56.23 | $67.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10.72 / $69.18 / $107.15
| Facility | | $10.72 | $69.18 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $79.43 / $93.33
| Professional | | $75.86 | $79.43 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $7.24 / $70.79 / $72.44
| Professional | | $7.24 | $70.79 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $131.83 / $151.36
| Facility | | $87.10 | $131.83 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $67.61
| Professional | | $64.57 | $64.57 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $93.33 / $102.33
| Professional | | $87.10 | $93.33 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4.37 / $43.65 / $58.88
| Facility | | $4.37 | $43.65 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $50.12 / $79.43
| Professional | | $41.69 | $50.12 | $79.43 |