- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $95.50 / $173.78
| Facility | | $57.54 | $95.50 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $144.54 / $512.86
| Professional | | $102.33 | $144.54 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Professional | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $831.76
| Facility | | $239.88 | $239.88 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $125.89 / $218.78
| Professional | | $123.03 | $125.89 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $239.88
| Professional | | $141.25 | $141.25 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $138.04
| Facility | | $131.83 | $131.83 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $131.83
| Professional | | $95.50 | $95.50 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $186.21 / $1,096.48
| Facility | | $114.82 | $186.21 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $114.82 / $1,174.90
| Professional | | $79.43 | $114.82 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $190.55 / $190.55
| Facility | | $95.50 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $112.20 / $177.83
| Professional | | $81.28 | $112.20 | $177.83 |