- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Facility | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $147.91 / $147.91
| Professional | | $112.20 | $147.91 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $363.08 / $363.08
| Facility | | $199.53 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $199.53 / $269.15
| Professional | | $186.21 | $199.53 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $794.33
| Facility | | $123.03 | $123.03 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $239.88 / $380.19
| Professional | | $123.03 | $239.88 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $239.88 / $363.08
| Facility | | $100.00 | $239.88 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Professional | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $316.23 / $891.25
| Facility | | $100.00 | $316.23 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $169.82 / $269.15
| Professional | | $107.15 | $169.82 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $13.80 / $79.43 / $173.78
| Professional | | $13.80 | $79.43 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $234.42 / $338.84
| Professional | | $154.88 | $234.42 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $39.81 / $52.48
| Professional | | $26.30 | $39.81 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $398.11 / $912.01
| Facility | | $123.03 | $398.11 | $912.01 |
- 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
- $10.96 / $95.50 / $181.97
| Facility | | $10.96 | $95.50 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $151.36 / $269.15
| Professional | | $95.50 | $151.36 | $269.15 |