- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $204.17 / $204.17
| Facility | | $128.82 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $245.47
| Professional | | $204.17 | $204.17 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $218.78 / $234.42
| Facility | | $173.78 | $218.78 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $234.42
| Professional | | $218.78 | $218.78 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $208.93 / $229.09
| Facility | | $144.54 | $208.93 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $281.84 / $407.38
| Professional | | $125.89 | $281.84 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $363.08 / $812.83
| Facility | | $234.42 | $363.08 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $1,258.93
| Professional | | $234.42 | $234.42 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $302.00 / $398.11
| Professional | | $269.15 | $302.00 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $208.93 / $309.03
| Facility | | $169.82 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $398.11 / $588.84
| Professional | | $302.00 | $398.11 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $223.87 / $1,202.26
| Professional | | $177.83 | $223.87 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $323.59 / $691.83
| Facility | | $102.33 | $323.59 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $141.25 / $263.03
| Professional | | $125.89 | $141.25 | $263.03 |