- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $38.90 / $38.90
| Facility | | $38.90 | $38.90 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $69.18 / $100.00
| Professional | | $46.77 | $69.18 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $109.65 / $186.21
| Facility | | $91.20 | $109.65 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $128.82 / $128.82
| Professional | | $123.03 | $128.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $72.44
| Facility | | $66.07 | $66.07 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $47.86 / $66.07
| Professional | | $47.86 | $47.86 | $66.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $109.65 / $128.82
| Facility | | $33.88 | $109.65 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $104.71 / $117.49
| Professional | | $63.10 | $104.71 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $100.00
| Professional | | $30.20 | $30.20 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $112.20 / $112.20
| Facility | | $109.65 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $123.03
| Professional | | $81.28 | $81.28 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $117.49 / $120.23
| Professional | | $91.20 | $117.49 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $56.23 / $64.57
| Facility | | $52.48 | $56.23 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $52.48 / $77.62
| Professional | | $48.98 | $52.48 | $77.62 |