- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $52.48
| Facility | | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $128.82
| Professional | | $52.48 | $52.48 | $128.82 |
- 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
- $89.13 / $112.20 / $125.89
| Professional | | $89.13 | $112.20 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $131.83 / $275.42
| Professional | | $52.48 | $131.83 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $100.00 / $1,148.15
| Facility | | $52.48 | $100.00 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $407.38
| Professional | | $52.48 | $52.48 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $100.00 / $407.38
| Professional | | $60.26 | $100.00 | $407.38 |
- 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
- $114.82 / $208.93 / $208.93
| Professional | | $114.82 | $208.93 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.10 / $100.00 / $162.18
| Facility | | $0.10 | $100.00 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $125.89 / $138.04
| Professional | | $100.00 | $125.89 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $52.48
| Facility | | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $52.48
| Professional | | $52.48 | $52.48 | $52.48 |