- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $128.82 / $158.49
| Facility | | $89.13 | $128.82 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $79.43 / $114.82
| Professional | | $60.26 | $79.43 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $177.83 / $363.08
| Facility | | $169.82 | $177.83 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $100.00 / $218.78
| Professional | | $81.28 | $100.00 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $114.82 / $162.18
| Facility | | $67.61 | $114.82 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $123.03 / $181.97
| Professional | | $87.10 | $123.03 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $117.49
| Facility | | $112.20 | $112.20 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $112.20
| Professional | | $81.28 | $81.28 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $112.20
| Professional | | $81.28 | $81.28 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $102.33 / $144.54
| Professional | | $72.44 | $102.33 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $190.55 / $346.74
| Professional | | $162.18 | $190.55 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $112.20 / $169.82
| Facility | | $52.48 | $112.20 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $77.62 / $107.15
| Professional | | $52.48 | $77.62 | $107.15 |