- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $204.17 / $338.84
| Facility | | $120.23 | $204.17 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $158.49
| Professional | | $120.23 | $120.23 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $223.87 / $630.96
| Facility | | $131.83 | $223.87 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $144.54 / $229.09
| Professional | | $120.23 | $144.54 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Facility | | $117.49 | $117.49 | $117.49 |
- 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
- $169.82 / $257.04 / $398.11
| Facility | | $169.82 | $257.04 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $120.23
| Facility | | $114.82 | $114.82 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $173.78
| Professional | | $120.23 | $120.23 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $147.91 / $169.82
| Professional | | $117.49 | $147.91 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $204.17 / $281.84
| Professional | | $112.20 | $204.17 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $120.23 / $251.19
| Facility | | $100.00 | $120.23 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $120.23 / $128.82
| Professional | | $117.49 | $120.23 | $128.82 |