- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $151.36
| Professional | | $141.25 | $141.25 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.03 / $165.96 / $190.55
| Facility | | $0.03 | $165.96 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $158.49 / $295.12
| Professional | | $141.25 | $158.49 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $134.90 / $158.49
| Facility | | $87.10 | $134.90 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $169.82 / $363.08
| Professional | | $134.90 | $169.82 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $251.19
| Professional | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $323.59 / $588.84
| Professional | | $218.78 | $323.59 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $229.09
| Facility | | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Professional | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $204.17 / $204.17
| Facility | | $147.91 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $251.19
| Professional | | $79.43 | $79.43 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $165.96 / $218.78
| Professional | | $128.82 | $165.96 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $177.83 / $331.13
| Professional | | $158.49 | $177.83 | $331.13 |