- 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
- $61.66 / $83.18 / $120.23
| Professional | | $61.66 | $83.18 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $89.13
| Facility | | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $66.07
| Professional | | $66.07 | $66.07 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $316.23 / $389.05
| Professional | | $109.65 | $316.23 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $154.88
| Facility | | $87.10 | $109.65 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $114.82 / $162.18
| Professional | | $107.15 | $114.82 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $141.25 / $144.54
| Facility | | $114.82 | $141.25 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $144.54 / $151.36
| Professional | | $128.82 | $144.54 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $125.89 / $181.97
| Facility | | $77.62 | $125.89 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $125.89 / $151.36
| Professional | | $66.07 | $125.89 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $229.09 / $562.34
| Facility | | $120.23 | $229.09 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $162.18 / $162.18
| Professional | | $144.54 | $162.18 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $107.15 / $234.42
| Facility | | $77.62 | $107.15 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $72.44 / $138.04
| Professional | | $56.23 | $72.44 | $138.04 |