- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $190.55 / $251.19
| Facility | | $95.50 | $190.55 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $95.50 / $97.72
| Professional | | $89.13 | $95.50 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $95.50
| Professional | | $74.13 | $74.13 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $128.82 / $190.55
| Professional | | $75.86 | $128.82 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $138.04 / $186.21
| Facility | | $95.50 | $138.04 | $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
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $74.13 / $165.96
| Professional | | $61.66 | $74.13 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $58.88
| Professional | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $95.50 / $102.33
| Facility | | $69.18 | $95.50 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $95.50 / $95.50
| Professional | | $69.18 | $95.50 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $89.13 / $107.15
| Facility | | $69.18 | $89.13 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $89.13 / $107.15
| Professional | | $69.18 | $89.13 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $74.13 / $147.91
| Facility | | $31.62 | $74.13 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $89.13 / $95.50
| Professional | | $52.48 | $89.13 | $95.50 |