- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Facility | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $173.78 / $1,584.89
| Professional | | $87.10 | $173.78 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $263.03 / $269.15
| Professional | | $239.88 | $263.03 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $309.03
| Facility | | $169.82 | $169.82 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $331.13 / $524.81
| Professional | | $169.82 | $331.13 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $309.03 / $1,445.44
| Facility | | $173.78 | $309.03 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $138.04 / $281.84
| Professional | | $91.20 | $138.04 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $302.00 / $741.31
| Professional | | $302.00 | $302.00 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $309.03
| Facility | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $691.83 / $741.31
| Professional | | $380.19 | $691.83 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $162.18 / $316.23
| Facility | | $104.71 | $162.18 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $138.04 / $213.80
| Professional | | $100.00 | $138.04 | $213.80 |