- 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
- $50.12 / $87.10 / $117.49
| Professional | | $50.12 | $87.10 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $169.82 / $199.53
| Facility | | $97.72 | $169.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $131.83 / $141.25
| Professional | | $125.89 | $131.83 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $91.20
| Facility | | $66.07 | $66.07 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $66.07 / $85.11
| Professional | | $56.23 | $66.07 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $11.75 / $79.43 / $117.49
| Facility | | $11.75 | $79.43 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $93.33 / $104.71
| Professional | | $89.13 | $93.33 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.32 / $81.28 / $83.18
| Professional | | $8.32 | $81.28 | $83.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $147.91 / $169.82
| Facility | | $97.72 | $147.91 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $75.86
| Professional | | $72.44 | $72.44 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $104.71 / $117.49
| Professional | | $95.50 | $104.71 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.01 / $48.98 / $72.44
| Facility | | $5.01 | $48.98 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $56.23 / $87.10
| Professional | | $50.12 | $56.23 | $87.10 |