- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $123.03 / $186.21
| Professional | | $102.33 | $123.03 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $229.09 / $323.59
| Facility | | $213.80 | $229.09 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $158.49 / $331.13
| Professional | | $112.20 | $158.49 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $245.47
| Professional | | $229.09 | $229.09 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $14.79 / $123.03 / $199.53
| Facility | | $14.79 | $123.03 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $128.82 / $208.93
| Professional | | $15.85 | $128.82 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $144.54
| Facility | | $131.83 | $131.83 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $169.82
| Professional | | $112.20 | $112.20 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $144.54
| Facility | | $131.83 | $131.83 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $131.83 / $169.82
| Professional | | $112.20 | $131.83 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $194.98 / $295.12
| Professional | | $117.49 | $194.98 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $288.40 / $398.11
| Professional | | $234.42 | $288.40 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9.55 / $77.62 / $141.25
| Facility | | $9.55 | $77.62 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $107.15 / $158.49
| Professional | | $70.79 | $107.15 | $158.49 |