- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $21.88 / $21.88
| Facility | | $21.88 | $21.88 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $70.79 / $83.18
| Professional | | $21.88 | $70.79 | $83.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.49 / $14.45 / $15.85
| Facility | | $13.49 | $14.45 | $15.85 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.39 / $91.20 / $100.00
| Professional | | $22.39 | $91.20 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $190.55 / $302.00
| Facility | | $144.54 | $190.55 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $22.39 / $70.79 / $125.89
| Facility | | $22.39 | $70.79 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $316.23
| Professional | | $109.65 | $109.65 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $194.98 / $245.47
| Professional | | $0.60 | $194.98 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $117.49 / $131.83
| Facility | | $70.79 | $117.49 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $125.89 / $125.89
| Professional | | $70.79 | $125.89 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $707.95
| Facility | | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |