- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $131.83 / $186.21
| Facility | | $109.65 | $131.83 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $112.20 / $275.42
| Professional | | $67.61 | $112.20 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $112.20 / $134.90
| Professional | | $95.50 | $112.20 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $97.72 / $147.91
| Professional | | $67.61 | $97.72 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $114.82 / $144.54
| Professional | | $69.18 | $114.82 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Facility | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $117.49 / $199.53
| Professional | | $75.86 | $117.49 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $104.71 / $190.55
| Facility | | $64.57 | $104.71 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $147.91 / $707.95
| Professional | | $100.00 | $147.91 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $144.54
| Professional | | $114.82 | $114.82 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $154.88
| Facility | | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $104.71 / $169.82
| Professional | | $72.44 | $104.71 | $169.82 |