- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $104.71
| Facility | | $93.33 | $93.33 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $104.71 / $138.04
| Professional | | $77.62 | $104.71 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $190.55
| Facility | | $177.83 | $177.83 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $165.96
| Professional | | $128.82 | $128.82 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $144.54
| Facility | | $120.23 | $120.23 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $134.90
| Professional | | $102.33 | $102.33 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $169.82 / $239.88
| Professional | | $128.82 | $169.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $269.15
| Professional | | $141.25 | $141.25 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $104.71 / $190.55
| Facility | | $77.62 | $104.71 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.18 / $104.71 / $602.56
| Facility | | $13.18 | $104.71 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $13.18 / $112.20 / $602.56
| Professional | | $13.18 | $112.20 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $8.32 / $75.86 / $117.49
| Facility | | $8.32 | $75.86 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $107.15 / $177.83
| Professional | | $89.13 | $107.15 | $177.83 |