- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $74.13
| Facility | | $74.13 | $74.13 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $74.13 / $512.86
| Professional | | $33.11 | $74.13 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $112.20 / $114.82
| Professional | | $102.33 | $112.20 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $131.83
| Facility | | $75.86 | $75.86 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $134.90 / $204.17
| Professional | | $75.86 | $134.90 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $128.82 / $549.54
| Facility | | $74.13 | $128.82 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $58.88 / $117.49
| Professional | | $38.90 | $58.88 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $316.23
| Professional | | $128.82 | $128.82 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $295.12 / $316.23
| Professional | | $162.18 | $295.12 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $63.10 / $123.03
| Facility | | $40.74 | $63.10 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $58.88 / $91.20
| Professional | | $42.66 | $58.88 | $91.20 |