- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $112.20 / $144.54
| Professional | | $64.57 | $112.20 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $186.21 / $239.88
| Facility | | $123.03 | $186.21 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $162.18 / $169.82
| Professional | | $158.49 | $162.18 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $44.67 / $97.72
| Facility | | $44.67 | $44.67 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $44.67 / $100.00
| Professional | | $38.02 | $44.67 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $14.45 / $87.10 / $144.54
| Facility | | $14.45 | $87.10 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $120.23 / $128.82
| Professional | | $112.20 | $120.23 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.47 / $104.71 / $104.71
| Professional | | $10.47 | $104.71 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $181.97 / $208.93
| Facility | | $123.03 | $181.97 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $93.33
| Professional | | $89.13 | $89.13 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $128.82 / $151.36
| Professional | | $120.23 | $128.82 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.89 / $52.48 / $93.33
| Facility | | $5.89 | $52.48 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $69.18 / $100.00
| Professional | | $60.26 | $69.18 | $100.00 |