- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Facility | | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $95.50 / $131.83
| Professional | | $54.95 | $95.50 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $169.82 / $204.17
| Facility | | $112.20 | $169.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $138.04 / $147.91
| Professional | | $134.90 | $138.04 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $85.11
| Facility | | $74.13 | $74.13 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $74.13 / $89.13
| Professional | | $63.10 | $74.13 | $89.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12.59 / $83.18 / $125.89
| Facility | | $12.59 | $83.18 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $104.71 / $117.49
| Professional | | $100.00 | $104.71 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $9.12 / $89.13 / $91.20
| Professional | | $9.12 | $89.13 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $169.82 / $190.55
| Facility | | $112.20 | $169.82 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $87.10
| Professional | | $81.28 | $81.28 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $117.49 / $128.82
| Professional | | $104.71 | $117.49 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.01 / $45.71 / $81.28
| Facility | | $5.01 | $45.71 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $58.88 / $87.10
| Professional | | $52.48 | $58.88 | $87.10 |