- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $123.03 / $123.03
| Facility | | $93.33 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $93.33 / $128.82
| Professional | | $67.61 | $93.33 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $165.96
| Facility | | $89.13 | $89.13 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $169.82 / $213.80
| Professional | | $91.20 | $169.82 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $190.55 / $208.93
| Professional | | $141.25 | $190.55 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $162.18 / $691.83
| Facility | | $100.00 | $162.18 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $89.13 / $245.47
| Professional | | $67.61 | $89.13 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $165.96 / $190.55
| Professional | | $162.18 | $165.96 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Facility | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $245.47 / $245.47
| Professional | | $125.89 | $245.47 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $74.13 / $104.71
| Facility | | $42.66 | $74.13 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $72.44 / $141.25
| Professional | | $61.66 | $72.44 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $138.04 / $138.04
| Professional | | $109.65 | $138.04 | $138.04 |