- 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
- $52.48 / $69.18 / $100.00
| Professional | | $52.48 | $69.18 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Facility | | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $67.61
| Professional | | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $257.04 / $309.03
| Professional | | $91.20 | $257.04 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $91.20 / $131.83
| Facility | | $70.79 | $91.20 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $95.50 / $134.90
| Professional | | $87.10 | $95.50 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $117.49 / $141.25
| Facility | | $95.50 | $117.49 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $120.23 / $144.54
| Professional | | $107.15 | $120.23 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $102.33 / $151.36
| Facility | | $70.79 | $102.33 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $104.71 / $125.89
| Professional | | $67.61 | $104.71 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $190.55 / $467.74
| Facility | | $100.00 | $190.55 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $134.90 / $134.90
| Professional | | $120.23 | $134.90 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $66.07 / $186.21
| Facility | | $52.48 | $66.07 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $57.54 / $109.65
| Professional | | $44.67 | $57.54 | $109.65 |