- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $37.15 / $37.15
| Facility | | $37.15 | $37.15 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $37.15 / $37.15
| Professional | | $20.89 | $37.15 | $37.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,162.28 / $3,388.44 / $4,168.69
| Facility | | $3,162.28 | $3,388.44 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.31 / $3.31 / $3.31
| Professional | | $3.31 | $3.31 | $3.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Facility | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.05 / $19.05 / $19.05
| Professional | | $19.05 | $19.05 | $19.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $37.15 / $81.28
| Facility | | $30.90 | $37.15 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $37.15 / $37.15
| Professional | | $28.18 | $37.15 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $38.90 / $50.12
| Professional | | $30.20 | $38.90 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $37.15 / $81.28
| Facility | | $30.90 | $37.15 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.05 / $19.05 / $19.05
| Professional | | $19.05 | $19.05 | $19.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.20 / $18.20 / $18.20
| Professional | | $18.20 | $18.20 | $18.20 |