- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $70.79
| Facility | | $70.79 | $70.79 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $70.79 / $104.71
| Professional | | $44.67 | $70.79 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $190.55 / $229.09
| Facility | | $104.71 | $190.55 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $117.49 / $134.90
| Professional | | $107.15 | $117.49 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $104.71
| Facility | | $57.54 | $57.54 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $57.54 / $107.15
| Professional | | $48.98 | $57.54 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.18 / $58.88 / $114.82
| Facility | | $13.18 | $58.88 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $77.62 / $81.28
| Professional | | $75.86 | $77.62 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.32 / $83.18 / $83.18
| Professional | | $8.32 | $83.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $58.88
| Professional | | $56.23 | $56.23 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $120.23
| Professional | | $81.28 | $81.28 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4.90 / $44.67 / $75.86
| Facility | | $4.90 | $44.67 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $64.57 / $100.00
| Professional | | $43.65 | $64.57 | $100.00 |