- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $302.00 / $398.11
| Facility | | $131.83 | $302.00 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $239.88
| Professional | | $128.82 | $128.82 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $141.25 / $5,011.87
| Facility | | $120.23 | $141.25 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $134.90 / $141.25
| Professional | | $131.83 | $134.90 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $457.09 / $489.78
| Facility | | $128.82 | $457.09 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Professional | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Facility | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $223.87 / $223.87
| Professional | | $194.98 | $223.87 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $380.19
| Facility | | $380.19 | $380.19 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $194.98 / $338.84
| Facility | | $128.82 | $194.98 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $141.25
| Professional | | $128.82 | $128.82 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $144.54 / $151.36
| Facility | | $30.20 | $144.54 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $125.89 / $151.36
| Professional | | $30.20 | $125.89 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Facility | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $177.83
| Professional | | $128.82 | $128.82 | $177.83 |