- 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
- $41.69 / $61.66 / $81.28
| Professional | | $41.69 | $61.66 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $79.43
| Professional | | $72.44 | $72.44 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $81.28 / $81.28
| Facility | | $41.69 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $85.11
| Professional | | $58.88 | $58.88 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $46.77 / $70.79
| Professional | | $43.65 | $46.77 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $83.18 / $141.25
| Facility | | $39.81 | $83.18 | $141.25 |
- 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
- $35.48 / $46.77 / $77.62
| Facility | | $35.48 | $46.77 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $46.77 / $70.79
| Professional | | $36.31 | $46.77 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $912.01
| Professional | | $912.01 | $912.01 | $912.01 |