- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $114.82
| Facility | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $85.11 / $114.82
| Professional | | $57.54 | $85.11 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $112.20
| Professional | | $102.33 | $102.33 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $107.15 / $107.15
| Facility | | $58.88 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $109.65
| Professional | | $77.62 | $77.62 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $89.13 / $89.13
| Professional | | $83.18 | $89.13 | $89.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $117.49 / $199.53
| Facility | | $54.95 | $117.49 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $66.07 / $107.15
| Facility | | $50.12 | $66.07 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $66.07 / $100.00
| Professional | | $51.29 | $66.07 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $741.31 / $741.31
| Facility | | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $1,445.44
| Professional | | $1,445.44 | $1,445.44 | $1,445.44 |