- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $208.93 / $501.19
| Facility | | $93.33 | $208.93 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $87.10 / $104.71
| Professional | | $83.18 | $87.10 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $100.00 / $134.90
| Facility | | $93.33 | $100.00 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $89.13 / $114.82
| Professional | | $83.18 | $89.13 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $91.20 / $125.89
| Facility | | $87.10 | $91.20 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $107.15 / $190.55
| Professional | | $87.10 | $107.15 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $177.83 / $223.87
| Facility | | $89.13 | $177.83 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $89.13
| Professional | | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $162.18 / $295.12
| Professional | | $112.20 | $162.18 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $446.68
| Facility | | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $467.74
| Professional | | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $104.71 / $134.90
| Facility | | $83.18 | $104.71 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $104.71
| Professional | | $89.13 | $89.13 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $269.15
| Facility | | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $89.13 / $104.71
| Professional | | $87.10 | $89.13 | $104.71 |