- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $89.13
| Facility | | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $100.00 / $169.82
| Professional | | $89.13 | $100.00 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $181.97 / $257.04
| Facility | | $173.78 | $181.97 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $128.82 / $269.15
| Professional | | $91.20 | $128.82 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12.30 / $91.20 / $158.49
| Facility | | $12.30 | $91.20 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.30 / $91.20 / $147.91
| Professional | | $12.30 | $91.20 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $74.13
| Facility | | $70.79 | $70.79 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $60.26 / $70.79
| Professional | | $51.29 | $60.26 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $70.79
| Facility | | $70.79 | $70.79 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $60.26 / $75.86
| Professional | | $51.29 | $60.26 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $120.23 / $194.98
| Professional | | $97.72 | $120.23 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $213.80 / $288.40
| Professional | | $173.78 | $213.80 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $7.76 / $58.88 / $123.03
| Facility | | $7.76 | $58.88 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $81.28 / $128.82
| Professional | | $54.95 | $81.28 | $128.82 |