- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $128.82 / $302.00
| Professional | | $91.20 | $128.82 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $151.36 / $257.04
| Professional | | $109.65 | $151.36 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $144.54 / $257.04
| Professional | | $138.04 | $144.54 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Facility | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $141.25 / $234.42
| Professional | | $109.65 | $141.25 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $114.82 / $204.17
| Professional | | $95.50 | $114.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $151.36 / $204.17
| Professional | | $123.03 | $151.36 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $144.54 / $229.09
| Facility | | $100.00 | $144.54 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Professional | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $141.25 / $223.87
| Facility | | $117.49 | $141.25 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $141.25 / $223.87
| Professional | | $117.49 | $141.25 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Facility | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $134.90 / $213.80
| Professional | | $95.50 | $134.90 | $213.80 |