- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Facility | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $154.88
| Professional | | $125.89 | $125.89 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $169.82
| Professional | | $134.90 | $134.90 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $295.12 / $436.52
| Facility | | $162.18 | $295.12 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $162.18 / $186.21
| Professional | | $123.03 | $162.18 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $125.89 / $147.91
| Facility | | $95.50 | $125.89 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $125.89 / $147.91
| Facility | | $95.50 | $125.89 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $223.87
| Professional | | $147.91 | $147.91 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $64.57 / $85.11
| Professional | | $54.95 | $64.57 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $89.13
| Facility | | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $213.80 / $295.12
| Professional | | $141.25 | $213.80 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $537.03 / $537.03
| Facility | | $426.58 | $537.03 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $194.98
| Professional | | $162.18 | $162.18 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $194.98
| Facility | | $83.18 | $83.18 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $234.42
| Professional | | $147.91 | $147.91 | $234.42 |