- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Facility | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $123.03 / $169.82
| Professional | | $72.44 | $123.03 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $218.78 / $269.15
| Facility | | $144.54 | $218.78 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $173.78 / $186.21
| Professional | | $165.96 | $173.78 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $123.03
| Facility | | $95.50 | $95.50 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $95.50 / $144.54
| Professional | | $81.28 | $95.50 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16.22 / $117.49 / $162.18
| Facility | | $16.22 | $117.49 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $134.90 / $154.88
| Professional | | $128.82 | $134.90 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.75 / $114.82 / $117.49
| Professional | | $11.75 | $114.82 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $218.78 / $245.47
| Facility | | $144.54 | $218.78 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $112.20
| Professional | | $107.15 | $107.15 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $154.88 / $165.96
| Professional | | $131.83 | $154.88 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6.92 / $66.07 / $104.71
| Facility | | $6.92 | $66.07 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $75.86 / $117.49
| Professional | | $70.79 | $75.86 | $117.49 |