- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $67.61
| Facility | | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $67.61 / $457.09
| Professional | | $30.20 | $67.61 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $102.33 / $104.71
| Professional | | $93.33 | $102.33 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $120.23
| Facility | | $60.26 | $60.26 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $125.89 / $181.97
| Professional | | $60.26 | $125.89 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $117.49 / $501.19
| Facility | | $64.57 | $117.49 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $35.48 / $53.70 / $107.15
| Professional | | $35.48 | $53.70 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $288.40
| Professional | | $117.49 | $117.49 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Facility | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $269.15 / $288.40
| Professional | | $147.91 | $269.15 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $56.23 / $109.65
| Facility | | $37.15 | $56.23 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $53.70 / $83.18
| Professional | | $38.90 | $53.70 | $83.18 |