- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $107.15 / $213.80
| Facility | | $75.86 | $107.15 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $131.83 / $281.84
| Professional | | $81.28 | $131.83 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $131.83 / $177.83
| Professional | | $107.15 | $131.83 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $51.29
| Facility | | $51.29 | $51.29 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $95.50 / $204.17
| Professional | | $64.57 | $95.50 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $151.36 / $151.36
| Facility | | $77.62 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $141.25 / $263.03
| Professional | | $91.20 | $141.25 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $109.65 / $162.18
| Professional | | $53.70 | $109.65 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $91.20 / $158.49
| Professional | | $50.12 | $91.20 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $93.33 / $117.49
| Facility | | $70.79 | $93.33 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $114.82 / $204.17
| Professional | | $74.13 | $114.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $70.79 / $138.04
| Professional | | $69.18 | $70.79 | $138.04 |