- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $97.72 / $97.72
| Facility | | $61.66 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $64.57 / $97.72
| Professional | | $61.66 | $64.57 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $245.47 / $302.00
| Facility | | $190.55 | $245.47 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $81.28 / $107.15
| Professional | | $64.57 | $81.28 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $69.18 / $151.36
| Professional | | $52.48 | $69.18 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $93.33 / $154.88
| Facility | | $60.26 | $93.33 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $107.15
| Professional | | $60.26 | $60.26 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $75.86 / $107.15
| Professional | | $67.61 | $75.86 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $245.47 / $302.00
| Facility | | $204.17 | $245.47 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $104.71 / $104.71
| Professional | | $89.13 | $104.71 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.06 / $63.10 / $104.71
| Facility | | $0.06 | $63.10 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $125.89 / $131.83
| Professional | | $63.10 | $125.89 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $63.10
| Facility | | $63.10 | $63.10 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $63.10
| Professional | | $63.10 | $63.10 | $63.10 |