- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $371.54 / $371.54
| Facility | | $53.70 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $79.43 / $165.96
| Professional | | $57.54 | $79.43 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $100.00 / $295.12
| Facility | | $74.13 | $100.00 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $154.88 / $162.18
| Professional | | $144.54 | $154.88 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $467.74
| Facility | | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $181.97 / $251.19
| Professional | | $66.07 | $181.97 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $141.25 / $263.03
| Facility | | $75.86 | $141.25 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $125.89 / $549.54
| Professional | | $75.86 | $125.89 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $181.97 / $288.40
| Professional | | $162.18 | $181.97 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $467.74
| Facility | | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $162.18 / $204.17
| Professional | | $123.03 | $162.18 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $165.96 / $229.09
| Professional | | $151.36 | $165.96 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $107.15 / $162.18
| Facility | | $30.90 | $107.15 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $114.82 / $194.98
| Professional | | $77.62 | $114.82 | $194.98 |