- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $66.07
| Facility | | $66.07 | $66.07 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $77.62 / $123.03
| Professional | | $57.54 | $77.62 | $123.03 |
- 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
- $100.00 / $128.82 / $269.15
| Professional | | $100.00 | $128.82 | $269.15 |
- 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
- $10.96 / $87.10 / $154.88
| Facility | | $10.96 | $87.10 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.48 / $87.10 / $128.82
| Professional | | $11.48 | $87.10 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $109.65
| Facility | | $81.28 | $81.28 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $69.18 / $109.65
| Professional | | $69.18 | $69.18 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $109.65
| Facility | | $81.28 | $81.28 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $81.28 / $107.15
| Professional | | $69.18 | $81.28 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $151.36 / $239.88
| Professional | | $120.23 | $151.36 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $181.97 / $269.15
| Professional | | $162.18 | $181.97 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $7.41 / $60.26 / $102.33
| Facility | | $7.41 | $60.26 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $77.62 / $128.82
| Professional | | $45.71 | $77.62 | $128.82 |