- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Facility | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $102.33 / $134.90
| Professional | | $57.54 | $102.33 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $169.82 / $218.78
| Facility | | $114.82 | $169.82 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $147.91 / $154.88
| Professional | | $144.54 | $147.91 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $87.10
| Facility | | $77.62 | $77.62 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $77.62 / $104.71
| Professional | | $66.07 | $77.62 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.18 / $83.18 / $131.83
| Facility | | $13.18 | $83.18 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $109.65 / $120.23
| Professional | | $102.33 | $109.65 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $9.55 / $95.50 / $95.50
| Professional | | $9.55 | $95.50 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $169.82 / $194.98
| Facility | | $114.82 | $169.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $87.10
| Professional | | $83.18 | $83.18 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $120.23 / $134.90
| Professional | | $109.65 | $120.23 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.37 / $47.86 / $85.11
| Facility | | $5.37 | $47.86 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $63.10 / $91.20
| Professional | | $54.95 | $63.10 | $91.20 |