- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $891.25 / $977.24
| Facility | | $87.10 | $891.25 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $79.43 / $114.82
| Professional | | $64.57 | $79.43 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $117.49 / $158.49
| Professional | | $114.82 | $117.49 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $467.74 / $891.25
| Facility | | $204.17 | $467.74 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $162.18
| Professional | | $154.88 | $154.88 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $100.00 / $169.82
| Professional | | $72.44 | $100.00 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $302.00 / $977.24
| Facility | | $87.10 | $302.00 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $123.03 / $190.55
| Professional | | $75.86 | $123.03 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $107.15 / $154.88
| Professional | | $72.44 | $107.15 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $125.89 / $186.21
| Facility | | $91.20 | $125.89 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $74.13 / $107.15
| Professional | | $57.54 | $74.13 | $107.15 |