- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $100.00 / $114.82
| Professional | | $61.66 | $100.00 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $31.62 / $31.62
| Professional | | $31.62 | $31.62 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $114.82
| Professional | | $77.62 | $77.62 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Facility | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $138.04
| Professional | | $83.18 | $83.18 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $660.69
| Facility | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $24.55 / $102.33 / $128.82
| Facility | | $24.55 | $102.33 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $100.00 / $112.20
| Professional | | $61.66 | $100.00 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $102.33 / $128.82
| Facility | | $23.99 | $102.33 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $138.04
| Professional | | $83.18 | $83.18 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $117.49 / $186.21
| Professional | | $83.18 | $117.49 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $38.02
| Professional | | $30.20 | $30.20 | $38.02 |