- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $302.00 / $562.34
| Facility | | $165.96 | $302.00 | $562.34 |
- 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 / $602.56
| Facility | | $173.78 | $173.78 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $169.82 / $436.52
| Professional | | $97.72 | $169.82 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $173.78 / $204.17
| Facility | | $169.82 | $173.78 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $173.78 / $263.03
| Professional | | $120.23 | $173.78 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $338.84 / $954.99
| Facility | | $229.09 | $338.84 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $151.36 / $630.96
| Professional | | $85.11 | $151.36 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $269.15 / $831.76
| Facility | | $151.36 | $269.15 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $239.88 / $1,412.54
| Professional | | $104.71 | $239.88 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $208.93 / $239.88
| Facility | | $61.66 | $208.93 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $173.78 / $331.13
| Professional | | $104.71 | $173.78 | $331.13 |