- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $154.88
| Facility | | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $154.88 / $218.78
| Professional | | $112.20 | $154.88 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $257.04 / $416.87
| Facility | | $169.82 | $257.04 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $281.84 / $288.40
| Professional | | $257.04 | $281.84 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $199.53
| Facility | | $123.03 | $123.03 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $123.03 / $154.88
| Professional | | $104.71 | $123.03 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $154.88 / $309.03
| Facility | | $100.00 | $154.88 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $177.83 / $190.55
| Professional | | $169.82 | $177.83 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.88 / $125.89 / $169.82
| Professional | | $12.88 | $125.89 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $257.04 / $316.23
| Facility | | $169.82 | $257.04 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $131.83
| Professional | | $125.89 | $125.89 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $239.88
| Professional | | $181.97 | $181.97 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10.23 / $95.50 / $169.82
| Facility | | $10.23 | $95.50 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $144.54 / $208.93
| Professional | | $95.50 | $144.54 | $208.93 |