- 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
- $38.90 / $53.70 / $81.28
| Professional | | $38.90 | $53.70 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $75.86
| Professional | | $70.79 | $70.79 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12.02 / $56.23 / $58.88
| Facility | | $12.02 | $56.23 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $41.69 / $64.57
| Professional | | $41.69 | $41.69 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $46.77 / $60.26
| Professional | | $43.65 | $46.77 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $81.28 / $138.04
| Facility | | $38.90 | $81.28 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $91.20 / $95.50
| Professional | | $0.60 | $91.20 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $41.69 / $75.86
| Facility | | $28.18 | $41.69 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $46.77 / $66.07
| Professional | | $34.67 | $46.77 | $66.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $436.52 / $436.52
| Facility | | $436.52 | $436.52 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $676.08
| Professional | | $467.74 | $467.74 | $676.08 |