- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $53.70
| Facility | | $53.70 | $53.70 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $64.57 / $177.83
| Professional | | $38.02 | $64.57 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $112.20 / $177.83
| Professional | | $100.00 | $112.20 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $72.44 / $72.44
| Professional | | $66.07 | $72.44 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $87.10 / $109.65
| Facility | | $85.11 | $87.10 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $109.65 / $190.55
| Professional | | $85.11 | $109.65 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $95.50 / $371.54
| Facility | | $54.95 | $95.50 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $56.23 / $100.00
| Professional | | $37.15 | $56.23 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $109.65 / $263.03
| Professional | | $107.15 | $109.65 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $245.47 / $263.03
| Professional | | $147.91 | $245.47 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $102.33 / $165.96
| Professional | | $77.62 | $102.33 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $66.07 / $107.15
| Facility | | $43.65 | $66.07 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $56.23 / $89.13
| Professional | | $37.15 | $56.23 | $89.13 |