- 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
- $46.77 / $67.61 / $83.18
| Professional | | $46.77 | $67.61 | $83.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $109.65
| Facility | | $91.20 | $91.20 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $91.20
| Professional | | $85.11 | $85.11 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Facility | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $91.20
| Professional | | $74.13 | $74.13 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $56.23 / $72.44
| Professional | | $51.29 | $56.23 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $89.13 / $154.88
| Facility | | $46.77 | $89.13 | $154.88 |
- 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
- $40.74 / $74.13 / $91.20
| Facility | | $40.74 | $74.13 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $54.95 / $77.62
| Professional | | $43.65 | $54.95 | $77.62 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $489.78
| Facility | | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $812.83
| Professional | | $575.44 | $575.44 | $812.83 |