- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $223.87 / $630.96
| Facility | | $87.10 | $223.87 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $134.90 / $269.15
| Professional | | $109.65 | $134.90 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $100.00
| Professional | | $97.72 | $97.72 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $162.18 / $194.98
| Facility | | $144.54 | $162.18 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.96 / $162.18 / $162.18
| Professional | | $10.96 | $162.18 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $177.83 / $660.69
| Facility | | $120.23 | $177.83 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $138.04 / $331.13
| Professional | | $81.28 | $138.04 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $97.72 / $123.03
| Professional | | $67.61 | $97.72 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $28.84 / $281.84
| Professional | | $26.30 | $28.84 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $147.91 / $204.17
| Facility | | $81.28 | $147.91 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $93.33 / $245.47
| Professional | | $69.18 | $93.33 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.44 / $162.18 / $162.18
| Professional | | $23.44 | $162.18 | $162.18 |