- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $380.19 / $3,630.78
| Facility | | $40.74 | $380.19 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $81.28
| Professional | | $30.20 | $30.20 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $38.90 / $97.72
| Professional | | $30.20 | $38.90 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $40.74
| Professional | | $30.20 | $30.20 | $40.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $269.15 / $416.87
| Facility | | $239.88 | $269.15 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $30.20 / $131.83
| Facility | | $28.84 | $30.20 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $42.66
| Professional | | $30.20 | $30.20 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $93.33 / $131.83
| Professional | | $33.11 | $93.33 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $144.54 / $158.49
| Facility | | $134.90 | $144.54 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $3,801.89 / $6,456.54
| Professional | | $50.12 | $3,801.89 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $102.33 / $102.33
| Facility | | $37.15 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $125.89 / $125.89
| Professional | | $30.20 | $125.89 | $125.89 |