- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $194.98
| Facility | | $81.28 | $81.28 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $70.79 / $125.89
| Professional | | $52.48 | $70.79 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $123.03 / $123.03
| Facility | | $109.65 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $144.54
| Professional | | $109.65 | $109.65 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $97.72
| Facility | | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $97.72
| Professional | | $70.79 | $70.79 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $165.96 / $363.08
| Facility | | $74.13 | $165.96 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $151.36 / $269.15
| Professional | | $74.13 | $151.36 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $97.72 / $107.15
| Professional | | $75.86 | $97.72 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $123.03 / $128.82
| Facility | | $100.00 | $123.03 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $128.82 / $128.82
| Professional | | $107.15 | $128.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $186.21 / $257.04
| Facility | | $112.20 | $186.21 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $123.03
| Professional | | $104.71 | $104.71 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Facility | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $144.54
| Professional | | $109.65 | $109.65 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $158.49 / $190.55
| Facility | | $77.62 | $158.49 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $77.62 / $112.20
| Professional | | $54.95 | $77.62 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $109.65 / $194.98
| Professional | | $53.70 | $109.65 | $194.98 |