- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $66.07
| Facility | | $66.07 | $66.07 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $66.07 / $426.58
| Professional | | $30.90 | $66.07 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $100.00 / $102.33
| Professional | | $91.20 | $100.00 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $61.66 / $117.49
| Facility | | $61.66 | $61.66 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $120.23 / $190.55
| Professional | | $61.66 | $120.23 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $114.82 / $501.19
| Facility | | $66.07 | $114.82 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $51.29 / $104.71
| Professional | | $34.67 | $51.29 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $281.84
| Professional | | $114.82 | $114.82 | $281.84 |
- 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
- $144.54 / $257.04 / $281.84
| Professional | | $144.54 | $257.04 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $57.54 / $114.82
| Facility | | $37.15 | $57.54 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $51.29 / $81.28
| Professional | | $38.02 | $51.29 | $81.28 |