- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.18 / $75.86 / $190.55
| Facility | | $13.18 | $75.86 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $77.62 / $190.55
| Professional | | $44.67 | $77.62 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $125.89 / $234.42
| Professional | | $102.33 | $125.89 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Facility | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $151.36 / $162.18
| Professional | | $117.49 | $151.36 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $229.09
| Facility | | $87.10 | $87.10 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $87.10
| Professional | | $63.10 | $63.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $97.72 / $162.18
| Professional | | $70.79 | $97.72 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $63.10 / $77.62
| Professional | | $40.74 | $63.10 | $77.62 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $64.57 / $169.82
| Facility | | $47.86 | $64.57 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $75.86 / $93.33
| Professional | | $57.54 | $75.86 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $162.18
| Professional | | $63.10 | $63.10 | $162.18 |