- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $134.90 / $398.11
| Facility | | $109.65 | $134.90 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $81.28 / $134.90
| Professional | | $54.95 | $81.28 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $229.09 / $257.04
| Facility | | $141.25 | $229.09 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $97.72 / $158.49
| Professional | | $44.67 | $97.72 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $194.98 / $223.87
| Professional | | $177.83 | $194.98 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $87.10 / $134.90
| Facility | | $85.11 | $87.10 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $104.71 / $128.82
| Professional | | $87.10 | $104.71 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $177.83
| Facility | | $87.10 | $87.10 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $173.78
| Professional | | $87.10 | $87.10 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $123.03 / $257.04
| Facility | | $64.57 | $123.03 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $97.72 / $123.03
| Professional | | $79.43 | $97.72 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $263.03 / $363.08
| Facility | | $131.83 | $263.03 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $79.43 / $104.71
| Professional | | $66.07 | $79.43 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $104.71 / $141.25
| Facility | | $40.74 | $104.71 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $37.15 / $104.71
| Professional | | $37.15 | $37.15 | $104.71 |