- 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
- $75.86 / $75.86 / $128.82
| Professional | | $75.86 | $75.86 | $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
- $72.44 / $91.20 / $125.89
| Professional | | $72.44 | $91.20 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $316.23 / $645.65
| Professional | | $75.86 | $316.23 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $128.82 / $1,148.15
| Facility | | $83.18 | $128.82 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $1,148.15
| Professional | | $83.18 | $83.18 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $100.00 / $1,148.15
| Professional | | $85.11 | $100.00 | $1,148.15 |
- 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
- $177.83 / $1,148.15 / $1,148.15
| Professional | | $177.83 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.07 / $70.79 / $117.49
| Facility | | $0.07 | $70.79 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $125.89 / $138.04
| Professional | | $70.79 | $125.89 | $138.04 |
- 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
- $75.86 / $75.86 / $75.86
| Professional | | $75.86 | $75.86 | $75.86 |