- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $75.86
| Facility | | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $75.86 / $102.33
| Professional | | $57.54 | $75.86 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $75.86
| Professional | | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $281.84 / $338.84
| Professional | | $97.72 | $281.84 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $95.50 / $141.25
| Facility | | $75.86 | $95.50 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $102.33 / $141.25
| Professional | | $93.33 | $102.33 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $123.03 / $125.89
| Facility | | $100.00 | $123.03 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $125.89 / $125.89
| Professional | | $114.82 | $125.89 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $109.65 / $162.18
| Facility | | $70.79 | $109.65 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $112.20 / $131.83
| Professional | | $75.86 | $112.20 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $204.17 / $501.19
| Facility | | $107.15 | $204.17 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $141.25 / $141.25
| Professional | | $128.82 | $141.25 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $81.28 / $208.93
| Facility | | $58.88 | $81.28 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $63.10 / $120.23
| Professional | | $50.12 | $63.10 | $120.23 |