- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $169.82 / $229.09
| Facility | | $81.28 | $169.82 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $151.36
| Professional | | $81.28 | $81.28 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $363.08
| Professional | | $218.78 | $218.78 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $218.78
| Professional | | $81.28 | $81.28 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $407.38 / $549.54
| Facility | | $218.78 | $407.38 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $218.78
| Professional | | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $186.21 / $218.78
| Professional | | $81.28 | $186.21 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $501.19
| Professional | | $251.19 | $251.19 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $100.00 / $302.00
| Facility | | $81.28 | $100.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $102.33 / $186.21
| Professional | | $100.00 | $102.33 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $218.78 / $323.59
| Facility | | $107.15 | $218.78 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $218.78 / $323.59
| Professional | | $107.15 | $218.78 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $72.44 / $158.49
| Facility | | $58.88 | $72.44 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $87.10 / $97.72
| Professional | | $63.10 | $87.10 | $97.72 |