- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $295.12 / $575.44
| Facility | | $79.43 | $295.12 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $107.15 / $263.03
| Professional | | $72.44 | $107.15 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $144.54 / $186.21
| Professional | | $104.71 | $144.54 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $89.13 / $114.82
| Facility | | $69.18 | $89.13 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $107.15 / $114.82
| Professional | | $89.13 | $107.15 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $173.78 / $208.93
| Facility | | $128.82 | $173.78 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $123.03 / $190.55
| Professional | | $83.18 | $123.03 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $79.43 / $120.23
| Professional | | $74.13 | $79.43 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $56.23 / $141.25
| Professional | | $32.36 | $56.23 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $117.49
| Facility | | $67.61 | $67.61 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $104.71 / $186.21
| Professional | | $83.18 | $104.71 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $109.65
| Professional | | $67.61 | $67.61 | $109.65 |