- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $125.89 / $331.13
| Facility | | $89.13 | $125.89 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $100.00 / $288.40
| Professional | | $83.18 | $100.00 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $131.83
| Facility | | $91.20 | $91.20 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $181.97 / $275.42
| Professional | | $114.82 | $181.97 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $147.91 / $251.19
| Professional | | $89.13 | $147.91 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Professional | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $131.83 / $208.93
| Facility | | $89.13 | $131.83 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $169.82 / $338.84
| Professional | | $131.83 | $169.82 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $144.54 / $194.98
| Facility | | $114.82 | $144.54 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $117.49 / $204.17
| Professional | | $87.10 | $117.49 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $575.44
| Facility | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $758.58
| Professional | | $758.58 | $758.58 | $758.58 |