- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $93.33
| Facility | | $53.70 | $53.70 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $75.86 / $141.25
| Professional | | $50.12 | $75.86 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.22 / $11.22 / $11.22
| Professional | | $11.22 | $11.22 | $11.22 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $371.54
| Facility | | $131.83 | $131.83 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $102.33 / $177.83
| Professional | | $56.23 | $102.33 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $100.00 / $223.87
| Professional | | $46.77 | $100.00 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $102.33 / $190.55
| Facility | | $53.70 | $102.33 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $131.83 / $371.54
| Professional | | $81.28 | $131.83 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $190.55 / $239.88
| Professional | | $117.49 | $190.55 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $162.18 / $239.88
| Professional | | $112.20 | $162.18 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $89.13 / $199.53
| Professional | | $38.02 | $89.13 | $199.53 |