- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $173.78 / $380.19
| Facility | | $109.65 | $173.78 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $281.84
| Professional | | $141.25 | $141.25 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $72.44 / $257.04
| Professional | | $57.54 | $72.44 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $208.93 / $371.54
| Facility | | $199.53 | $208.93 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $141.25 / $239.88
| Professional | | $100.00 | $141.25 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $302.00 / $338.84
| Facility | | $194.98 | $302.00 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $123.03 / $208.93
| Professional | | $66.07 | $123.03 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $158.49 / $676.08
| Facility | | $128.82 | $158.49 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $91.20 / $707.95
| Professional | | $64.57 | $91.20 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $141.25 / $169.82
| Facility | | $60.26 | $141.25 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $91.20 / $190.55
| Professional | | $64.57 | $91.20 | $190.55 |