- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Facility | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $87.10 / $645.65
| Professional | | $34.67 | $87.10 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $131.83 / $134.90
| Professional | | $120.23 | $131.83 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $69.18 / $154.88
| Facility | | $69.18 | $69.18 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $151.36 / $234.42
| Professional | | $69.18 | $151.36 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $151.36 / $588.84
| Facility | | $79.43 | $151.36 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $72.44 / $138.04
| Professional | | $45.71 | $72.44 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $371.54
| Professional | | $151.36 | $151.36 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $154.88
| Facility | | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $338.84 / $371.54
| Professional | | $190.55 | $338.84 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $83.18 / $128.82
| Facility | | $64.57 | $83.18 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $67.61 / $107.15
| Professional | | $50.12 | $67.61 | $107.15 |