- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Facility | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $56.23 / $117.49
| Professional | | $48.98 | $56.23 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $158.49
| Facility | | $134.90 | $134.90 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $97.72 / $128.82
| Professional | | $56.23 | $97.72 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $114.82 / $199.53
| Professional | | $60.26 | $114.82 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $87.10 / $120.23
| Facility | | $52.48 | $87.10 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $117.49 / $407.38
| Professional | | $75.86 | $117.49 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $128.82 / $169.82
| Professional | | $91.20 | $128.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $125.89 / $154.88
| Professional | | $104.71 | $125.89 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $128.82 / $162.18
| Professional | | $123.03 | $128.82 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.07 / $0.07 / $0.07
| Facility | | $0.07 | $0.07 | $0.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $109.65 / $162.18
| Professional | | $69.18 | $109.65 | $162.18 |