- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Facility | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $87.10 / $100.00
| Professional | | $42.66 | $87.10 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $120.23
| Professional | | $100.00 | $100.00 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $331.13 / $457.09
| Facility | | $281.84 | $331.13 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $154.88 / $204.17
| Professional | | $52.48 | $154.88 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $89.13 / $107.15
| Facility | | $77.62 | $89.13 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $128.82 / $245.47
| Professional | | $95.50 | $128.82 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $100.00 / $165.96
| Facility | | $77.62 | $100.00 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $52.48 / $97.72
| Professional | | $41.69 | $52.48 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $33.11 / $70.79
| Professional | | $25.12 | $33.11 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $107.15 / $165.96
| Professional | | $79.43 | $107.15 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $162.18 / $316.23
| Professional | | $107.15 | $162.18 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $676.08
| Facility | | $213.80 | $213.80 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $478.63 / $933.25
| Professional | | $51.29 | $478.63 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $35.48 / $52.48 / $79.43
| Professional | | $35.48 | $52.48 | $79.43 |