- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $89.13
| Facility | | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $107.15
| Professional | | $89.13 | $89.13 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $245.47 / $302.00
| Facility | | $190.55 | $245.47 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $117.49 / $125.89
| Professional | | $93.33 | $117.49 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $239.88 / $489.78
| Professional | | $89.13 | $239.88 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $120.23 / $269.15
| Facility | | $93.33 | $120.23 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $223.87
| Professional | | $93.33 | $93.33 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $112.20 / $269.15
| Professional | | $107.15 | $112.20 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $245.47 / $302.00
| Facility | | $204.17 | $245.47 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $269.15 / $269.15
| Professional | | $131.83 | $269.15 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.09 / $91.20 / $151.36
| Facility | | $0.09 | $91.20 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $125.89 / $138.04
| Professional | | $91.20 | $125.89 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $89.13
| Facility | | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $89.13
| Professional | | $89.13 | $89.13 | $89.13 |