- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $263.03 / $562.34
| Facility | | $147.91 | $263.03 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $162.18 / $501.19
| Professional | | $123.03 | $162.18 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $263.03
| Professional | | $263.03 | $263.03 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $162.18 / $269.15
| Professional | | $141.25 | $162.18 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $41.69 / $144.54
| Facility | | $30.90 | $41.69 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $173.78 / $223.87
| Professional | | $162.18 | $173.78 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $398.11 / $912.01
| Facility | | $213.80 | $398.11 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $165.96 / $338.84
| Professional | | $95.50 | $165.96 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $181.97 / $426.58
| Facility | | $102.33 | $181.97 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $190.55 / $1,023.29
| Professional | | $109.65 | $190.55 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $239.88 / $489.78
| Facility | | $162.18 | $239.88 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $165.96 / $263.03
| Professional | | $100.00 | $165.96 | $263.03 |