- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $281.84 / $281.84
| Facility | | $89.13 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $91.20 / $281.84
| Professional | | $39.81 | $91.20 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $138.04 / $138.04
| Professional | | $125.89 | $138.04 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $74.13 / $158.49
| Facility | | $70.79 | $74.13 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $154.88 / $239.88
| Professional | | $70.79 | $154.88 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $154.88 / $588.84
| Facility | | $91.20 | $154.88 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $67.61 / $141.25
| Professional | | $46.77 | $67.61 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $380.19
| Professional | | $154.88 | $154.88 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Facility | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $354.81 / $380.19
| Professional | | $194.98 | $354.81 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $67.61 / $131.83
| Facility | | $43.65 | $67.61 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $67.61 / $112.20
| Professional | | $46.77 | $67.61 | $112.20 |