- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $660.69 / $660.69
| Facility | | $87.10 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $79.43 / $147.91
| Professional | | $63.10 | $79.43 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Facility | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Professional | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $323.59 / $389.05
| Professional | | $109.65 | $323.59 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $109.65 / $151.36
| Facility | | $89.13 | $109.65 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $117.49 / $162.18
| Professional | | $107.15 | $117.49 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $141.25 / $144.54
| Facility | | $114.82 | $141.25 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Professional | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $125.89 / $173.78
| Facility | | $79.43 | $125.89 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $125.89 / $151.36
| Professional | | $79.43 | $125.89 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $229.09 / $562.34
| Facility | | $120.23 | $229.09 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $162.18 / $162.18
| Professional | | $147.91 | $162.18 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $112.20 / $234.42
| Facility | | $72.44 | $112.20 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $72.44 / $138.04
| Professional | | $64.57 | $72.44 | $138.04 |