- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $97.72 / $97.72
| Facility | | $95.50 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $95.50 / $199.53
| Professional | | $72.44 | $95.50 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $138.04
| Facility | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $109.65 / $257.04
| Professional | | $63.10 | $109.65 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $120.23 / $165.96
| Professional | | $87.10 | $120.23 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $107.15 / $173.78
| Facility | | $95.50 | $107.15 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $144.54 / $630.96
| Professional | | $83.18 | $144.54 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $165.96 / $263.03
| Professional | | $138.04 | $165.96 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $138.04
| Facility | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $125.89 / $263.03
| Professional | | $104.71 | $125.89 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $107.15 / $208.93
| Professional | | $79.43 | $107.15 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $83.18
| Facility | | $83.18 | $83.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $117.49 / $239.88
| Professional | | $79.43 | $117.49 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $131.83 / $144.54
| Professional | | $109.65 | $131.83 | $144.54 |