- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $125.89 / $169.82
| Facility | | $109.65 | $125.89 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $112.20 / $251.19
| Professional | | $89.13 | $112.20 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Professional | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $741.31
| Facility | | $213.80 | $213.80 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $123.03 / $194.98
| Professional | | $83.18 | $123.03 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $213.80
| Professional | | $128.82 | $128.82 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $147.91
| Facility | | $141.25 | $141.25 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $141.25
| Professional | | $102.33 | $102.33 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $169.82 / $977.24
| Facility | | $104.71 | $169.82 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $104.71 / $1,047.13
| Professional | | $72.44 | $104.71 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $169.82 / $169.82
| Facility | | $87.10 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $100.00 / $158.49
| Professional | | $72.44 | $100.00 | $158.49 |