- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $109.65 / $141.25
| Facility | | $93.33 | $109.65 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $123.03 / $177.83
| Professional | | $93.33 | $123.03 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $177.83 / $239.88
| Professional | | $123.03 | $177.83 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $186.21
| Professional | | $144.54 | $144.54 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $165.96 / $295.12
| Professional | | $104.71 | $165.96 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $147.91 / $194.98
| Professional | | $112.20 | $147.91 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $263.03
| Professional | | $263.03 | $263.03 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $147.91 / $218.78
| Facility | | $120.23 | $147.91 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $120.23 / $128.82
| Professional | | $60.26 | $120.23 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $208.93 / $288.40
| Facility | | $128.82 | $208.93 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $218.78 / $309.03
| Professional | | $141.25 | $218.78 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $1,096.48
| Facility | | $107.15 | $107.15 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $141.25 / $251.19
| Professional | | $97.72 | $141.25 | $251.19 |