- 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 / $158.49
| Professional | | $72.44 | $123.03 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $194.98 / $245.47
| Facility | | $134.90 | $194.98 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $158.49
| Professional | | $147.91 | $147.91 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $100.00
| Facility | | $57.54 | $57.54 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $57.54 / $102.33
| Professional | | $48.98 | $57.54 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $87.10 / $158.49
| Facility | | $47.86 | $87.10 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $128.82 / $141.25
| Professional | | $123.03 | $128.82 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.96 / $107.15 / $109.65
| Professional | | $10.96 | $107.15 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $199.53 / $229.09
| Facility | | $134.90 | $199.53 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $104.71
| Professional | | $97.72 | $97.72 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $141.25 / $154.88
| Professional | | $125.89 | $141.25 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.25 / $52.48 / $97.72
| Facility | | $5.25 | $52.48 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $66.07 / $104.71
| Professional | | $61.66 | $66.07 | $104.71 |