- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Facility | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $112.20 / $169.82
| Professional | | $81.28 | $112.20 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $158.49
| Professional | | $151.36 | $151.36 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $128.82 / $128.82
| Facility | | $32.36 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $144.54
| Professional | | $95.50 | $95.50 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $97.72 / $125.89
| Professional | | $91.20 | $97.72 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $169.82 / $288.40
| Facility | | $81.28 | $169.82 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $87.10 / $158.49
| Facility | | $58.88 | $87.10 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $97.72 / $138.04
| Professional | | $72.44 | $97.72 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $933.25 / $933.25
| Facility | | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $1,412.54
| Professional | | $1,000.00 | $1,000.00 | $1,412.54 |