- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $181.97 / $316.23
| Facility | | $112.20 | $181.97 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $117.49 / $489.78
| Professional | | $112.20 | $117.49 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $218.78 / $371.54
| Facility | | $109.65 | $218.78 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $181.97
| Professional | | $109.65 | $109.65 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $151.36 / $229.09
| Professional | | $134.90 | $151.36 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $204.17 / $275.42
| Facility | | $151.36 | $204.17 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Professional | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $112.20 / $288.40
| Professional | | $93.33 | $112.20 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $239.88
| Professional | | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $257.04 / $489.78
| Facility | | $112.20 | $257.04 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $162.18 / $478.63
| Facility | | $104.71 | $162.18 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $162.18 / $478.63
| Professional | | $104.71 | $162.18 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $151.36 / $269.15
| Facility | | $109.65 | $151.36 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $112.20 / $158.49
| Professional | | $107.15 | $112.20 | $158.49 |