- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $67.61
| Facility | | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $79.43 / $109.65
| Professional | | $58.88 | $79.43 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $138.04 / $194.98
| Facility | | $128.82 | $138.04 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $128.82 / $218.78
| Professional | | $97.72 | $128.82 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $169.82 / $181.97
| Professional | | $158.49 | $169.82 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9.55 / $81.28 / $134.90
| Facility | | $9.55 | $81.28 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.48 / $87.10 / $134.90
| Professional | | $11.48 | $87.10 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $89.13
| Facility | | $81.28 | $81.28 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $69.18 / $102.33
| Professional | | $69.18 | $69.18 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $81.28
| Facility | | $81.28 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $81.28 / $100.00
| Professional | | $64.57 | $81.28 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $151.36 / $223.87
| Professional | | $91.20 | $151.36 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $199.53 / $269.15
| Professional | | $162.18 | $199.53 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $7.41 / $60.26 / $97.72
| Facility | | $7.41 | $60.26 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $77.62 / $128.82
| Professional | | $45.71 | $77.62 | $128.82 |