- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $64.57 / $114.82
| Professional | | $54.95 | $64.57 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $177.83
| Facility | | $107.15 | $107.15 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $120.23
| Professional | | $100.00 | $100.00 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $436.52 / $602.56
| Facility | | $128.82 | $436.52 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $173.78 / $199.53
| Professional | | $93.33 | $173.78 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $104.71 / $162.18
| Facility | | $64.57 | $104.71 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $158.49 / $177.83
| Professional | | $104.71 | $158.49 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $117.49 / $537.03
| Facility | | $64.57 | $117.49 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $102.33 / $223.87
| Professional | | $87.10 | $102.33 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $64.57 / $79.43
| Professional | | $50.12 | $64.57 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $165.96 / $257.04
| Professional | | $97.72 | $165.96 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $125.89 / $245.47
| Professional | | $87.10 | $125.89 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $208.93 / $537.03
| Facility | | $128.82 | $208.93 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $173.78 / $812.83
| Professional | | $93.33 | $173.78 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $95.50 / $162.18
| Facility | | $61.66 | $95.50 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $97.72 / $151.36
| Professional | | $64.57 | $97.72 | $151.36 |