- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $100.00 / $165.96
| Facility | | $53.70 | $100.00 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $53.70 / $70.79
| Professional | | $52.48 | $53.70 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $100.00 / $275.42
| Facility | | $57.54 | $100.00 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $61.66 / $91.20
| Professional | | $53.70 | $61.66 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $52.48
| Facility | | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $70.79
| Professional | | $52.48 | $52.48 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $104.71 / $177.83
| Facility | | $53.70 | $104.71 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $69.18
| Professional | | $53.70 | $53.70 | $69.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $53.70 / $72.44
| Facility | | $51.29 | $53.70 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $74.13
| Professional | | $53.70 | $53.70 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $58.88 / $75.86
| Professional | | $52.48 | $58.88 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $61.66 / $102.33
| Professional | | $50.12 | $61.66 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $104.71
| Facility | | $53.70 | $53.70 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $53.70 / $60.26
| Professional | | $48.98 | $53.70 | $60.26 |