- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $371.54 / $1,148.15
| Facility | | $93.33 | $371.54 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $95.50 / $123.03
| Professional | | $87.10 | $95.50 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $190.55 / $323.59
| Facility | | $95.50 | $190.55 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $158.49
| Professional | | $95.50 | $95.50 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $147.91 / $218.78
| Professional | | $128.82 | $147.91 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $177.83 / $239.88
| Facility | | $131.83 | $177.83 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Professional | | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $93.33 / $112.20
| Professional | | $81.28 | $93.33 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $47.86 / $47.86
| Professional | | $47.86 | $47.86 | $47.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $97.72 / $158.49
| Facility | | $40.74 | $97.72 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $104.71 / $141.25
| Facility | | $91.20 | $104.71 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $104.71 / $141.25
| Professional | | $91.20 | $104.71 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $95.50 / $194.98
| Facility | | $91.20 | $95.50 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $93.33 / $112.20
| Professional | | $91.20 | $93.33 | $112.20 |