- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Facility | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $102.33 / $151.36
| Professional | | $57.54 | $102.33 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $177.83 / $295.12
| Facility | | $117.49 | $177.83 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $169.82 / $194.98
| Professional | | $162.18 | $169.82 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $134.90
| Facility | | $81.28 | $81.28 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $81.28 / $100.00
| Professional | | $69.18 | $81.28 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $17.78 / $107.15 / $177.83
| Facility | | $17.78 | $107.15 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $117.49 / $125.89
| Professional | | $109.65 | $117.49 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.48 / $112.20 / $114.82
| Professional | | $11.48 | $112.20 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $177.83 / $218.78
| Facility | | $117.49 | $177.83 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $91.20
| Professional | | $87.10 | $87.10 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $125.89 / $162.18
| Professional | | $123.03 | $125.89 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6.92 / $64.57 / $97.72
| Facility | | $6.92 | $64.57 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $83.18 / $128.82
| Professional | | $64.57 | $83.18 | $128.82 |