- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $63.10
| Facility | | $63.10 | $63.10 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $47.86 / $67.61
| Professional | | $34.67 | $47.86 | $67.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $51.29
| Facility | | $51.29 | $51.29 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $38.02 / $38.02
| Professional | | $38.02 | $38.02 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $177.83 / $223.87
| Professional | | $79.43 | $177.83 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $79.43 / $107.15
| Facility | | $63.10 | $79.43 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $85.11 / $114.82
| Professional | | $77.62 | $85.11 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $102.33 / $104.71
| Facility | | $79.43 | $102.33 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $83.18 / $114.82
| Professional | | $79.43 | $83.18 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $81.28 / $117.49
| Facility | | $47.86 | $81.28 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $91.20 / $109.65
| Professional | | $38.02 | $91.20 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $165.96 / $407.38
| Facility | | $87.10 | $165.96 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $117.49 / $117.49
| Professional | | $104.71 | $117.49 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $61.66 / $131.83
| Facility | | $52.48 | $61.66 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $39.81 / $75.86
| Professional | | $33.88 | $39.81 | $75.86 |