- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Facility | | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $144.54 / $323.59
| Professional | | $93.33 | $144.54 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $114.82 / $181.97
| Professional | | $97.72 | $114.82 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $67.61 / $70.79
| Facility | | $66.07 | $67.61 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $109.65 / $128.82
| Professional | | $85.11 | $109.65 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $501.19
| Facility | | $177.83 | $177.83 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $151.36 / $269.15
| Professional | | $102.33 | $151.36 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $112.20 / $141.25
| Professional | | $57.54 | $112.20 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $154.88
| Professional | | $32.36 | $33.11 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $239.88
| Facility | | $102.33 | $102.33 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $125.89 / $213.80
| Professional | | $91.20 | $125.89 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $109.65
| Professional | | $79.43 | $79.43 | $109.65 |