- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $66.07
| Facility | | $66.07 | $66.07 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $66.07 / $162.18
| Professional | | $44.67 | $66.07 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $57.54
| Facility | | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $42.66 / $42.66
| Professional | | $42.66 | $42.66 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $199.53 / $239.88
| Professional | | $85.11 | $199.53 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $83.18 / $112.20
| Facility | | $66.07 | $83.18 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $87.10 / $123.03
| Professional | | $66.07 | $87.10 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $107.15 / $109.65
| Facility | | $87.10 | $107.15 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $109.65 / $114.82
| Professional | | $89.13 | $109.65 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $91.20 / $125.89
| Facility | | $53.70 | $91.20 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $95.50 / $114.82
| Professional | | $42.66 | $95.50 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $173.78 / $436.52
| Facility | | $91.20 | $173.78 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $123.03 / $123.03
| Professional | | $112.20 | $123.03 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $50.12 / $147.91
| Facility | | $41.69 | $50.12 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $44.67 / $85.11
| Professional | | $36.31 | $44.67 | $85.11 |