- 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
- $33.11 / $79.43 / $524.81
| Professional | | $33.11 | $79.43 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $120.23 / $120.23
| Professional | | $109.65 | $120.23 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $138.04
| Facility | | $64.57 | $64.57 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $158.49 / $208.93
| Professional | | $64.57 | $158.49 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $134.90 / $549.54
| Facility | | $79.43 | $134.90 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $61.66 / $123.03
| Professional | | $40.74 | $61.66 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $331.13
| Professional | | $134.90 | $134.90 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $138.04
| Facility | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $309.03 / $331.13
| Professional | | $169.82 | $309.03 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $60.26 / $120.23
| Facility | | $39.81 | $60.26 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $58.88 / $93.33
| Professional | | $42.66 | $58.88 | $93.33 |