- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $151.36 / $223.87
| Facility | | $81.28 | $151.36 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $104.71
| Professional | | $81.28 | $81.28 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $151.36 / $416.87
| Facility | | $87.10 | $151.36 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $95.50 / $154.88
| Professional | | $81.28 | $95.50 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $81.28
| Facility | | $81.28 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Professional | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $173.78 / $269.15
| Facility | | $114.82 | $173.78 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $81.28
| Professional | | $81.28 | $81.28 | $81.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $81.28
| Facility | | $75.86 | $75.86 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $120.23
| Professional | | $81.28 | $81.28 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $100.00 / $117.49
| Professional | | $81.28 | $100.00 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $134.90 / $190.55
| Professional | | $75.86 | $134.90 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $81.28 / $165.96
| Facility | | $66.07 | $81.28 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $81.28 / $87.10
| Professional | | $77.62 | $81.28 | $87.10 |