- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $107.15 / $169.82
| Professional | | $75.86 | $107.15 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $398.11
| Professional | | $128.82 | $128.82 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $17.38 / $128.82 / $229.09
| Facility | | $17.38 | $128.82 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $17.38 / $128.82 / $229.09
| Professional | | $17.38 | $128.82 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $112.20
| Facility | | $109.65 | $109.65 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $109.65 / $165.96
| Professional | | $93.33 | $109.65 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $134.90 / $165.96
| Professional | | $100.00 | $134.90 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $177.83
| Professional | | $169.82 | $169.82 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9.33 / $70.79 / $120.23
| Facility | | $9.33 | $70.79 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $114.82 / $190.55
| Professional | | $74.13 | $114.82 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $169.82
| Facility | | $165.96 | $165.96 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $177.83
| Professional | | $169.82 | $169.82 | $177.83 |