- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $53.70
| Facility | | $53.70 | $53.70 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $85.11 / $128.82
| Professional | | $50.12 | $85.11 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $158.49 / $323.59
| Professional | | $112.20 | $158.49 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $190.55 / $302.00
| Facility | | $162.18 | $190.55 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $87.10 / $112.20
| Professional | | $67.61 | $87.10 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $74.13 / $134.90
| Facility | | $54.95 | $74.13 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $81.28 / $218.78
| Facility | | $57.54 | $81.28 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $218.78 / $1,023.29
| Professional | | $52.48 | $218.78 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $54.95 / $70.79
| Professional | | $50.12 | $54.95 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Professional | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $151.36 / $213.80
| Professional | | $70.79 | $151.36 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $707.95 / $707.95
| Facility | | $147.91 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $1,023.29 / $1,023.29
| Professional | | $275.42 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $72.44
| Professional | | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $213.80 / $213.80
| Professional | | $120.23 | $213.80 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $812.83 / $1,071.52
| Facility | | $239.88 | $812.83 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $169.82 / $537.03
| Professional | | $50.12 | $169.82 | $537.03 |