- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $165.96 / $165.96
| Facility | | $95.50 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $95.50 / $112.20
| Professional | | $93.33 | $95.50 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $89.13 / $147.91
| Facility | | $47.86 | $89.13 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $89.13 / $117.49
| Professional | | $81.28 | $89.13 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $83.18 / $186.21
| Facility | | $81.28 | $83.18 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $95.50
| Professional | | $74.13 | $74.13 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $89.13 / $97.72
| Facility | | $74.13 | $89.13 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $89.13 / $95.50
| Professional | | $74.13 | $89.13 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $56.23
| Professional | | $56.23 | $56.23 | $56.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Facility | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $85.11 / $89.13
| Professional | | $69.18 | $85.11 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $74.13
| Professional | | $74.13 | $74.13 | $74.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $31.62 / $39.81
| Facility | | $31.62 | $31.62 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $89.13 / $89.13
| Professional | | $36.31 | $89.13 | $89.13 |