- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $281.84 / $446.68
| Facility | | $169.82 | $281.84 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $104.71 / $223.87
| Professional | | $48.98 | $104.71 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $100.00 / $117.49
| Facility | | $48.98 | $100.00 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $151.36
| Professional | | $100.00 | $100.00 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $144.54 / $218.78
| Professional | | $102.33 | $144.54 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $107.15 / $162.18
| Facility | | $69.18 | $107.15 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $154.88 / $549.54
| Professional | | $63.10 | $154.88 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $114.82 / $162.18
| Professional | | $109.65 | $114.82 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $112.20 / $162.18
| Professional | | $102.33 | $112.20 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $107.15 / $144.54
| Professional | | $74.13 | $107.15 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $97.72 / $186.21
| Professional | | $56.23 | $97.72 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $120.23 / $177.83
| Professional | | $97.72 | $120.23 | $177.83 |