- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Facility | | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $107.15 / $169.82
| Professional | | $77.62 | $107.15 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $190.55 / $269.15
| Facility | | $177.83 | $190.55 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $158.49 / $295.12
| Professional | | $141.25 | $158.49 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $14.79 / $112.20 / $194.98
| Facility | | $14.79 | $112.20 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.79 / $114.82 / $169.82
| Professional | | $14.79 | $114.82 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $151.36
| Facility | | $114.82 | $114.82 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $151.36
| Professional | | $97.72 | $97.72 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $151.36
| Facility | | $114.82 | $114.82 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $114.82 / $151.36
| Professional | | $97.72 | $114.82 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $186.21 / $302.00
| Professional | | $151.36 | $186.21 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $263.03 / $354.81
| Professional | | $213.80 | $263.03 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9.55 / $75.86 / $134.90
| Facility | | $9.55 | $75.86 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $102.33 / $158.49
| Professional | | $61.66 | $102.33 | $158.49 |