- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $114.82
| Facility | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $114.82 / $141.25
| Professional | | $64.57 | $114.82 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $158.49 / $204.17
| Facility | | $114.82 | $158.49 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $131.83 / $138.04
| Professional | | $128.82 | $131.83 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $83.18
| Facility | | $79.43 | $79.43 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $79.43 / $97.72
| Professional | | $67.61 | $79.43 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12.30 / $83.18 / $123.03
| Facility | | $12.30 | $83.18 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $123.03 / $134.90
| Professional | | $114.82 | $123.03 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $9.12 / $89.13 / $91.20
| Professional | | $9.12 | $89.13 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $186.21 / $204.17
| Facility | | $123.03 | $186.21 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $93.33
| Professional | | $89.13 | $89.13 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $128.82 / $131.83
| Professional | | $95.50 | $128.82 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4.90 / $43.65 / $91.20
| Facility | | $4.90 | $43.65 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $58.88 / $91.20
| Professional | | $50.12 | $58.88 | $91.20 |