- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $389.05 / $977.24
| Facility | | $169.82 | $389.05 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $169.82 / $288.40
| Professional | | $128.82 | $169.82 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $199.53 / $234.42
| Facility | | $173.78 | $199.53 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.96 / $199.53 / $199.53
| Professional | | $10.96 | $199.53 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $213.80 / $812.83
| Facility | | $144.54 | $213.80 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $165.96 / $398.11
| Professional | | $100.00 | $165.96 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $117.49 / $151.36
| Professional | | $95.50 | $117.49 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $162.18 / $338.84
| Professional | | $131.83 | $162.18 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $177.83 / $245.47
| Facility | | $97.72 | $177.83 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $112.20 / $269.15
| Professional | | $83.18 | $112.20 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $199.53 / $199.53
| Professional | | $117.49 | $199.53 | $199.53 |