- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $169.82
| Facility | | $72.44 | $72.44 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $61.66 / $100.00
| Professional | | $47.86 | $61.66 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $109.65 / $109.65
| Facility | | $95.50 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $125.89
| Professional | | $95.50 | $95.50 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Facility | | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $91.20
| Professional | | $77.62 | $77.62 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $144.54 / $316.23
| Facility | | $64.57 | $144.54 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $131.83 / $234.42
| Professional | | $64.57 | $131.83 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $112.20 / $112.20
| Professional | | $60.26 | $112.20 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $112.20 / $112.20
| Facility | | $109.65 | $112.20 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $162.18 / $223.87
| Facility | | $97.72 | $162.18 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $109.65
| Professional | | $91.20 | $91.20 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $125.89
| Professional | | $95.50 | $95.50 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $165.96 / $165.96
| Facility | | $67.61 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $67.61 / $97.72
| Professional | | $47.86 | $67.61 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $79.43 / $169.82
| Professional | | $61.66 | $79.43 | $169.82 |