- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $97.72
| Facility | | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $97.72 / $131.83
| Professional | | $56.23 | $97.72 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $169.82 / $223.87
| Facility | | $112.20 | $169.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $147.91 / $154.88
| Professional | | $138.04 | $147.91 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $89.13
| Facility | | $74.13 | $74.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $74.13 / $95.50
| Professional | | $63.10 | $74.13 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.18 / $89.13 / $131.83
| Facility | | $13.18 | $89.13 | $131.83 |
- 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
- $9.33 / $93.33 / $93.33
| Professional | | $9.33 | $93.33 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $165.96 / $190.55
| Facility | | $112.20 | $165.96 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $85.11
| Professional | | $81.28 | $81.28 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $117.49 / $134.90
| Professional | | $109.65 | $117.49 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.25 / $47.86 / $81.28
| Facility | | $5.25 | $47.86 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $60.26 / $89.13
| Professional | | $54.95 | $60.26 | $89.13 |