- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $58.88
| Facility | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $58.88 / $363.08
| Professional | | $21.88 | $58.88 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $89.13 / $91.20
| Professional | | $81.28 | $89.13 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $43.65 / $104.71
| Facility | | $43.65 | $43.65 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $102.33 / $158.49
| Professional | | $43.65 | $102.33 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $102.33 / $371.54
| Facility | | $58.88 | $102.33 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $42.66 / $93.33
| Professional | | $28.84 | $42.66 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $251.19
| Professional | | $102.33 | $102.33 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $234.42 / $251.19
| Professional | | $128.82 | $234.42 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $26.92 / $41.69 / $81.28
| Facility | | $26.92 | $41.69 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $42.66 / $69.18
| Professional | | $30.90 | $42.66 | $69.18 |