- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $144.54 / $575.44
| Facility | | $97.72 | $144.54 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $104.71 / $245.47
| Professional | | $83.18 | $104.71 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $69.18 / $69.18
| Professional | | $69.18 | $69.18 | $69.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $257.04 / $436.52
| Facility | | $112.20 | $257.04 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $151.36 / $269.15
| Professional | | $89.13 | $151.36 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Professional | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $141.25 / $218.78
| Facility | | $95.50 | $141.25 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $95.50 / $208.93
| Professional | | $26.30 | $95.50 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $128.82 / $389.05
| Facility | | $38.02 | $128.82 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $125.89 / $229.09
| Professional | | $91.20 | $125.89 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $741.31 / $741.31
| Facility | | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $741.31 / $831.76
| Professional | | $741.31 | $741.31 | $831.76 |