- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $77.62
| Facility | | $77.62 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $77.62 / $707.95
| Professional | | $38.90 | $77.62 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $120.23 / $120.23
| Professional | | $107.15 | $120.23 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $138.04
| Facility | | $79.43 | $79.43 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $141.25 / $234.42
| Professional | | $79.43 | $141.25 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $141.25 / $645.65
| Facility | | $79.43 | $141.25 | $645.65 |
- 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
- $47.86 / $72.44 / $141.25
| Facility | | $47.86 | $72.44 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $61.66 / $95.50
| Professional | | $44.67 | $61.66 | $95.50 |