- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $295.12 / $338.84
| Facility | | $169.82 | $295.12 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $151.36 / $288.40
| Professional | | $114.82 | $151.36 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $616.60
| Facility | | $173.78 | $173.78 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $107.15 / $302.00
| Professional | | $69.18 | $107.15 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $257.04 / $457.09
| Facility | | $245.47 | $257.04 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $173.78 / $194.98
| Professional | | $123.03 | $173.78 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $331.13 / $426.58
| Facility | | $177.83 | $331.13 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $89.13 / $234.42
| Professional | | $74.13 | $89.13 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $208.93 / $831.76
| Facility | | $151.36 | $208.93 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $104.71 / $870.96
| Professional | | $74.13 | $104.71 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $173.78 / $208.93
| Facility | | $74.13 | $173.78 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $104.71 / $234.42
| Professional | | $74.13 | $104.71 | $234.42 |