- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $204.17 / $741.31
| Facility | | $107.15 | $204.17 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $117.49 / $181.97
| Professional | | $100.00 | $117.49 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Professional | | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $151.36 / $177.83
| Facility | | $131.83 | $151.36 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.96 / $151.36 / $151.36
| Professional | | $10.96 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $131.83 / $616.60
| Facility | | $89.13 | $131.83 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $120.23 / $269.15
| Professional | | $70.79 | $120.23 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $120.23
| Professional | | $91.20 | $91.20 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $100.00 / $165.96
| Professional | | $91.20 | $100.00 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $134.90 / $151.36
| Facility | | $63.10 | $134.90 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $63.10 / $199.53
| Professional | | $52.48 | $63.10 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $151.36 / $151.36
| Professional | | $91.20 | $151.36 | $151.36 |