- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $173.78 / $426.58
| Facility | | $112.20 | $173.78 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $112.20 / $213.80
| Professional | | $85.11 | $112.20 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $446.68
| Facility | | $128.82 | $128.82 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $112.20 / $309.03
| Professional | | $63.10 | $112.20 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $426.58
| Facility | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $128.82 / $194.98
| Professional | | $89.13 | $128.82 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $251.19 / $724.44
| Facility | | $169.82 | $251.19 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $95.50 / $229.09
| Professional | | $61.66 | $95.50 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $204.17 / $616.60
| Facility | | $112.20 | $204.17 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $107.15 / $724.44
| Professional | | $53.70 | $107.15 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $154.88 / $177.83
| Facility | | $46.77 | $154.88 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $77.62 / $181.97
| Professional | | $53.70 | $77.62 | $181.97 |