- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $107.15
| Facility | | $95.50 | $95.50 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $83.18 / $123.03
| Professional | | $58.88 | $83.18 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $173.78
| Facility | | $87.10 | $87.10 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $181.97 / $223.87
| Professional | | $87.10 | $181.97 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $138.04 / $154.88
| Professional | | $128.82 | $138.04 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $181.97 / $707.95
| Facility | | $104.71 | $181.97 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $93.33 / $257.04
| Professional | | $69.18 | $93.33 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $173.78 / $208.93
| Professional | | $169.82 | $173.78 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Facility | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $257.04 / $257.04
| Professional | | $158.49 | $257.04 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $158.49 / $363.08
| Facility | | $52.48 | $158.49 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $75.86 / $147.91
| Professional | | $69.18 | $75.86 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $151.36 / $151.36
| Professional | | $120.23 | $151.36 | $151.36 |