- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $275.42 / $398.11
| Facility | | $112.20 | $275.42 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $128.82 / $173.78
| Professional | | $100.00 | $128.82 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $316.23 / $316.23
| Facility | | $316.23 | $316.23 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $275.42 / $346.74
| Professional | | $186.21 | $275.42 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $239.88 / $263.03
| Professional | | $144.54 | $239.88 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $173.78 / $407.38
| Facility | | $144.54 | $173.78 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $177.83 / $724.44
| Professional | | $87.10 | $177.83 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $186.21
| Professional | | $173.78 | $173.78 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $354.81 / $354.81
| Facility | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $158.49 / $309.03
| Professional | | $144.54 | $158.49 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $331.13
| Facility | | $144.54 | $144.54 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $93.33 / $398.11
| Professional | | $87.10 | $93.33 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Professional | | $144.54 | $144.54 | $144.54 |