- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Facility | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.88 / $18.20 / $138.04
| Professional | | $12.88 | $18.20 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $120.23 / $363.08
| Professional | | $30.90 | $120.23 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $128.82 / $190.55
| Facility | | $95.50 | $128.82 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $24.55 / $44.67 / $51.29
| Professional | | $24.55 | $44.67 | $51.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.18 / $112.20 / $154.88
| Facility | | $13.18 | $112.20 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Professional | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.18 / $109.65 / $154.88
| Facility | | $13.18 | $109.65 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $186.21 / $812.83
| Professional | | $23.99 | $186.21 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $50.12 / $70.79
| Professional | | $32.36 | $50.12 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $208.93 / $338.84
| Professional | | $131.83 | $208.93 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $812.83
| Facility | | $269.15 | $269.15 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $489.78 / $812.83
| Professional | | $20.89 | $489.78 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $23.99 / $23.99
| Facility | | $23.99 | $23.99 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $141.25 / $407.38
| Professional | | $23.99 | $141.25 | $407.38 |