- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $100.00 / $100.00
| Facility | | $79.43 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $85.11 / $100.00
| Professional | | $79.43 | $85.11 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $223.87 / $269.15
| Facility | | $177.83 | $223.87 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $114.82 / $134.90
| Professional | | $91.20 | $114.82 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $208.93 / $263.03
| Professional | | $120.23 | $208.93 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $104.71 / $177.83
| Facility | | $81.28 | $104.71 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $138.04 / $204.17
| Professional | | $117.49 | $138.04 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $128.82 / $165.96
| Professional | | $91.20 | $128.82 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $208.93 / $269.15
| Facility | | $165.96 | $208.93 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $199.53 / $199.53
| Professional | | $109.65 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $181.97 / $199.53
| Professional | | $173.78 | $181.97 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.14 / $138.04 / $223.87
| Facility | | $0.14 | $138.04 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $138.04
| Professional | | $125.89 | $125.89 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Facility | | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Professional | | $91.20 | $91.20 | $91.20 |