- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Facility | | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $95.50 / $128.82
| Professional | | $52.48 | $95.50 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $204.17
| Facility | | $109.65 | $162.18 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $125.89 / $138.04
| Professional | | $117.49 | $125.89 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $75.86
| Facility | | $72.44 | $72.44 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $72.44 / $89.13
| Professional | | $61.66 | $72.44 | $89.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $63.10 / $128.82
| Facility | | $38.90 | $63.10 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $100.00 / $114.82
| Professional | | $93.33 | $100.00 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $9.12 / $89.13 / $91.20
| Professional | | $9.12 | $89.13 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $186.21
| Facility | | $109.65 | $162.18 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $83.18
| Professional | | $79.43 | $79.43 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $114.82 / $128.82
| Professional | | $102.33 | $114.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4.79 / $45.71 / $77.62
| Facility | | $4.79 | $45.71 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $56.23 / $83.18
| Professional | | $51.29 | $56.23 | $83.18 |