- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Facility | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $165.96 / $194.98
| Professional | | $117.49 | $165.96 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $31.62 / $38.02
| Facility | | $31.62 | $31.62 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $79.43
| Professional | | $70.79 | $70.79 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $147.91 / $204.17
| Facility | | $28.84 | $147.91 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $125.89 / $147.91
| Professional | | $107.15 | $125.89 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $158.49 / $223.87
| Facility | | $36.31 | $158.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $28.84 / $28.84
| Professional | | $28.84 | $28.84 | $28.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12.88 / $16.60 / $478.63
| Facility | | $12.88 | $16.60 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.13 / $17.78 / $75.86
| Professional | | $8.13 | $17.78 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $346.74 / $346.74
| Facility | | $100.00 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $912.01
| Professional | | $912.01 | $912.01 | $912.01 |