- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $97.72 / $208.93
| Facility | | $63.10 | $97.72 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $97.72 / $165.96
| Professional | | $64.57 | $97.72 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $97.72
| Professional | | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $181.97 / $501.19
| Facility | | $107.15 | $181.97 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $104.71 / $162.18
| Professional | | $89.13 | $104.71 | $162.18 |
- 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
- $131.83 / $131.83 / $131.83
| Professional | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $239.88 / $281.84
| Facility | | $208.93 | $239.88 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Professional | | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $95.50 / $151.36
| Facility | | $30.20 | $95.50 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $114.82
| Professional | | $95.50 | $95.50 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $141.25
| Professional | | $97.72 | $123.03 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $107.15 / $229.09
| Professional | | $91.20 | $107.15 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $102.33 / $177.83
| Facility | | $87.10 | $102.33 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $97.72 / $102.33
| Professional | | $79.43 | $97.72 | $102.33 |