- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $223.87
| Facility | | $134.90 | $134.90 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $104.71 / $239.88
| Professional | | $64.57 | $104.71 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $151.36 / $186.21
| Professional | | $87.10 | $151.36 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $125.89 / $190.55
| Professional | | $72.44 | $125.89 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $141.25 / $251.19
| Professional | | $74.13 | $141.25 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $112.20 / $186.21
| Facility | | $66.07 | $112.20 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $199.53 / $660.69
| Professional | | $109.65 | $199.53 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $158.49 / $213.80
| Professional | | $141.25 | $158.49 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $165.96 / $234.42
| Professional | | $128.82 | $165.96 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $213.80 / $269.15
| Professional | | $91.20 | $213.80 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.11 / $0.11 / $141.25
| Facility | | $0.11 | $0.11 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $125.89 / $218.78
| Professional | | $79.43 | $125.89 | $218.78 |