- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $64.57 / $436.52
| Professional | | $28.84 | $64.57 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $97.72 / $100.00
| Professional | | $89.13 | $97.72 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $114.82
| Facility | | $57.54 | $57.54 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $120.23 / $177.83
| Professional | | $57.54 | $120.23 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $109.65 / $478.63
| Facility | | $58.88 | $109.65 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $51.29 / $102.33
| Professional | | $33.88 | $51.29 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $275.42
| Professional | | $112.20 | $112.20 | $275.42 |
- 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
- $141.25 / $257.04 / $275.42
| Professional | | $141.25 | $257.04 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $35.48 / $54.95 / $107.15
| Facility | | $35.48 | $54.95 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $51.29 / $79.43
| Professional | | $37.15 | $51.29 | $79.43 |