- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $288.40 / $812.83
| Facility | | $112.20 | $288.40 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $141.25 / $288.40
| Professional | | $112.20 | $141.25 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $60.26 / $85.11
| Professional | | $50.12 | $60.26 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $141.25 / $165.96
| Facility | | $114.82 | $141.25 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.00 / $141.25 / $141.25
| Professional | | $10.00 | $141.25 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $107.15 / $575.44
| Facility | | $72.44 | $107.15 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $117.49 / $223.87
| Professional | | $69.18 | $117.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Professional | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.25 / $39.81 / $93.33
| Professional | | $5.25 | $39.81 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $128.82 / $141.25
| Facility | | $60.26 | $128.82 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $66.07 / $190.55
| Professional | | $50.12 | $66.07 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Professional | | $85.11 | $85.11 | $85.11 |