- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $102.33 / $870.96
| Facility | | $85.11 | $102.33 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $107.15 / $177.83
| Professional | | $85.11 | $107.15 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $154.88 / $398.11
| Professional | | $151.36 | $154.88 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $208.93
| Facility | | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $194.98 / $208.93
| Professional | | $151.36 | $194.98 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $323.59
| Facility | | $112.20 | $112.20 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $112.20
| Professional | | $83.18 | $83.18 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $141.25 / $141.25
| Facility | | $100.00 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $123.03 / $208.93
| Professional | | $89.13 | $123.03 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $107.15 / $134.90
| Professional | | $69.18 | $107.15 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $93.33 / $245.47
| Facility | | $69.18 | $93.33 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $100.00 / $128.82
| Professional | | $79.43 | $100.00 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $208.93
| Professional | | $107.15 | $107.15 | $208.93 |