- 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
- $79.43 / $87.10 / $107.15
| Professional | | $79.43 | $87.10 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $125.89
| Professional | | $123.03 | $123.03 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $138.04
| Professional | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $120.23
| Facility | | $100.00 | $100.00 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $114.82
| Professional | | $85.11 | $85.11 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $128.82 / $181.97
| Professional | | $114.82 | $128.82 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $134.90
| Professional | | $107.15 | $107.15 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $87.10 / $186.21
| Facility | | $57.54 | $87.10 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10.00 / $81.28 / $165.96
| Facility | | $10.00 | $81.28 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.00 / $64.57 / $154.88
| Professional | | $10.00 | $64.57 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $7.41 / $61.66 / $109.65
| Facility | | $7.41 | $61.66 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $87.10 / $134.90
| Professional | | $72.44 | $87.10 | $134.90 |