- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $97.72 / $302.00
| Facility | | $21.38 | $97.72 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $97.72 / $213.80
| Professional | | $69.18 | $97.72 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $131.83 / $234.42
| Professional | | $97.72 | $131.83 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $323.59 / $1,096.48
| Facility | | $208.93 | $323.59 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $128.82 / $128.82
| Professional | | $95.50 | $128.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $114.82
| Facility | | $97.72 | $97.72 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $173.78
| Professional | | $70.79 | $70.79 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $173.78 / $257.04
| Professional | | $141.25 | $173.78 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Professional | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $128.82
| Professional | | $91.20 | $91.20 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $141.25 / $239.88
| Facility | | $61.66 | $141.25 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $85.11 / $245.47
| Professional | | $67.61 | $85.11 | $245.47 |