- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $371.54 / $851.14
| Facility | | $89.13 | $371.54 | $851.14 |
- 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
- $12.02 / $85.11 / $173.78
| Professional | | $12.02 | $85.11 | $173.78 |
- 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
- $14.13 / $141.25 / $141.25
| Professional | | $14.13 | $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 / $25.70 / $114.82
| Professional | | $5.25 | $25.70 | $114.82 |
- 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
- $64.57 / $85.11 / $190.55
| Professional | | $64.57 | $85.11 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Professional | | $85.11 | $85.11 | $85.11 |