- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $134.90
| Facility | | $120.23 | $120.23 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $81.28 / $346.74
| Professional | | $63.10 | $81.28 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Facility | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $162.18 / $263.03
| Professional | | $81.28 | $162.18 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $181.97 / $354.81
| Professional | | $109.65 | $181.97 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $173.78 / $426.58
| Facility | | $95.50 | $173.78 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $181.97 / $1,174.90
| Professional | | $85.11 | $181.97 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $162.18 / $478.63
| Professional | | $97.72 | $162.18 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $169.82 / $181.97
| Professional | | $162.18 | $169.82 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $138.04 / $173.78
| Professional | | $79.43 | $138.04 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $63.10
| Facility | | $63.10 | $63.10 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $104.71 / $323.59
| Professional | | $85.11 | $104.71 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $169.82 / $169.82
| Professional | | $144.54 | $169.82 | $169.82 |