- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $63.10
| Facility | | $63.10 | $63.10 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $63.10 / $549.54
| Professional | | $30.20 | $63.10 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $95.50 / $97.72
| Professional | | $87.10 | $95.50 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $112.20
| Facility | | $81.28 | $81.28 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $131.83 / $181.97
| Professional | | $81.28 | $131.83 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $109.65 / $489.78
| Facility | | $63.10 | $109.65 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $48.98 / $100.00
| Professional | | $33.11 | $48.98 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $269.15
| Professional | | $109.65 | $109.65 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $245.47 / $269.15
| Professional | | $138.04 | $245.47 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $56.23 / $109.65
| Facility | | $36.31 | $56.23 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $48.98 / $74.13
| Professional | | $36.31 | $48.98 | $74.13 |