- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $56.23
| Facility | | $56.23 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $56.23 / $512.86
| Professional | | $28.18 | $56.23 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $85.11 / $85.11
| Professional | | $77.62 | $85.11 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $97.72
| Facility | | $66.07 | $66.07 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $114.82 / $169.82
| Professional | | $66.07 | $114.82 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $100.00 / $478.63
| Facility | | $56.23 | $100.00 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $43.65 / $93.33
| Professional | | $29.51 | $43.65 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $97.72 / $234.42
| Professional | | $95.50 | $97.72 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $97.72
| Facility | | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $218.78 / $234.42
| Professional | | $123.03 | $218.78 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $52.48 / $102.33
| Facility | | $33.88 | $52.48 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $43.65 / $67.61
| Professional | | $31.62 | $43.65 | $67.61 |