- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $100.00 / $120.23
| Facility | | $89.13 | $100.00 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $169.82
| Professional | | $97.72 | $123.03 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $275.42
| Professional | | $194.98 | $194.98 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $338.84 / $512.86
| Facility | | $288.40 | $338.84 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $186.21 / $257.04
| Professional | | $109.65 | $186.21 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $251.19 / $346.74
| Professional | | $114.82 | $251.19 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $138.04 / $223.87
| Facility | | $107.15 | $138.04 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $251.19 / $794.33
| Professional | | $104.71 | $251.19 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $257.04 / $331.13
| Professional | | $245.47 | $257.04 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $269.15 / $331.13
| Professional | | $263.03 | $269.15 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $125.89 / $173.78
| Professional | | $97.72 | $125.89 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $218.78 / $302.00
| Professional | | $114.82 | $218.78 | $302.00 |