- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $81.28
| Facility | | $81.28 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $81.28 / $81.28
| Professional | | $52.48 | $81.28 | $81.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $218.78 / $218.78
| Facility | | $120.23 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $120.23 / $162.18
| Professional | | $102.33 | $120.23 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $93.33 / $457.09
| Facility | | $74.13 | $93.33 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $138.04 / $234.42
| Professional | | $74.13 | $138.04 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $89.13 / $162.18
| Facility | | $38.02 | $89.13 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Professional | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $147.91 / $537.03
| Facility | | $38.02 | $147.91 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $69.18 / $114.82
| Professional | | $56.23 | $69.18 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $54.95 / $66.07
| Professional | | $39.81 | $54.95 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $112.20 / $204.17
| Professional | | $69.18 | $112.20 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $25.12 / $33.88
| Professional | | $15.85 | $25.12 | $33.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $239.88 / $537.03
| Facility | | $74.13 | $239.88 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $74.13 / $89.13
| Professional | | $63.10 | $74.13 | $89.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.75 / $44.67 / $91.20
| Facility | | $5.75 | $44.67 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $66.07 / $117.49
| Professional | | $41.69 | $66.07 | $117.49 |