- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $295.12 / $295.12
| Facility | | $114.82 | $295.12 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $114.82 / $114.82
| Professional | | $69.18 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $43.65
| Professional | | $30.20 | $30.20 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Professional | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $114.82 / $162.18
| Facility | | $91.20 | $114.82 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $128.82 / $169.82
| Professional | | $114.82 | $128.82 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $114.82 / $173.78
| Facility | | $69.18 | $114.82 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Professional | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $50.12 / $70.79
| Professional | | $32.36 | $50.12 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Facility | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.62 / $1.62 / $1.62
| Professional | | $1.62 | $1.62 | $1.62 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $190.55 / $251.19
| Facility | | $58.88 | $190.55 | $251.19 |