- 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
- $89.13 / $89.13 / $97.72
| Professional | | $89.13 | $89.13 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $144.54 / $302.00
| Professional | | $89.13 | $144.54 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $218.78 / $389.05
| Facility | | $134.90 | $218.78 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $125.89 / $223.87
| Professional | | $93.33 | $125.89 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $91.20 / $199.53
| Facility | | $89.13 | $91.20 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Professional | | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $95.50 / $223.87
| Facility | | $93.33 | $95.50 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $234.42
| Professional | | $93.33 | $93.33 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $58.88 / $70.79
| Professional | | $32.36 | $58.88 | $70.79 |
- 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
- $69.18 / $91.20 / $147.91
| Professional | | $69.18 | $91.20 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $229.09 / $446.68
| Professional | | $141.25 | $229.09 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $190.55 / $389.05
| Facility | | $89.13 | $190.55 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $102.33 / $436.52
| Professional | | $89.13 | $102.33 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $147.91
| Professional | | $120.23 | $120.23 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $213.80
| Facility | | $91.20 | $91.20 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $125.89 / $151.36
| Professional | | $91.20 | $125.89 | $151.36 |