- 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
- $50.12 / $87.10 / $114.82
| Professional | | $50.12 | $87.10 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $141.25 / $190.55
| Facility | | $95.50 | $141.25 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $128.82 / $138.04
| Professional | | $120.23 | $128.82 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $95.50
| Facility | | $66.07 | $66.07 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $66.07 / $87.10
| Professional | | $56.23 | $66.07 | $87.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12.30 / $79.43 / $123.03
| Facility | | $12.30 | $79.43 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $91.20 / $100.00
| Professional | | $85.11 | $91.20 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.51 / $83.18 / $85.11
| Professional | | $8.51 | $83.18 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $141.25 / $165.96
| Facility | | $95.50 | $141.25 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $69.18 / $72.44
| Professional | | $69.18 | $69.18 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $100.00 / $120.23
| Professional | | $97.72 | $100.00 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.13 / $51.29 / $70.79
| Facility | | $5.13 | $51.29 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $58.88 / $91.20
| Professional | | $50.12 | $58.88 | $91.20 |