- 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
- $72.44 / $95.50 / $95.50
| Professional | | $72.44 | $95.50 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $269.15 / $269.15
| Facility | | $147.91 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $147.91 / $199.53
| Professional | | $87.10 | $147.91 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $61.66 / $588.84
| Facility | | $61.66 | $61.66 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $181.97 / $281.84
| Professional | | $61.66 | $181.97 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $95.50 / $173.78
| Facility | | $39.81 | $95.50 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $70.79
| Professional | | $70.79 | $70.79 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $165.96 / $645.65
| Facility | | $39.81 | $165.96 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $72.44 / $134.90
| Professional | | $58.88 | $72.44 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $58.88 / $89.13
| Professional | | $50.12 | $58.88 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $138.04 / $251.19
| Professional | | $70.79 | $138.04 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.50 / $31.62 / $43.65
| Professional | | $19.50 | $31.62 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $295.12 / $645.65
| Facility | | $61.66 | $295.12 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $61.66 / $102.33
| Professional | | $52.48 | $61.66 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6.31 / $44.67 / $97.72
| Facility | | $6.31 | $44.67 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $72.44 / $147.91
| Professional | | $48.98 | $72.44 | $147.91 |