- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $134.90
| Facility | | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $154.88 / $245.47
| Professional | | $112.20 | $154.88 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $281.84 / $389.05
| Facility | | $263.03 | $281.84 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $229.09 / $478.63
| Professional | | $204.17 | $229.09 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $323.59 / $323.59
| Professional | | $302.00 | $323.59 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $162.18 / $275.42
| Facility | | $21.38 | $162.18 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $162.18 / $251.19
| Professional | | $20.89 | $162.18 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $213.80
| Facility | | $165.96 | $165.96 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $218.78
| Professional | | $141.25 | $141.25 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $213.80
| Facility | | $165.96 | $165.96 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $165.96 / $218.78
| Professional | | $141.25 | $165.96 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $269.15 / $426.58
| Professional | | $213.80 | $269.15 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $380.19 / $512.86
| Professional | | $309.03 | $380.19 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.80 / $109.65 / $190.55
| Facility | | $13.80 | $109.65 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $144.54 / $229.09
| Professional | | $89.13 | $144.54 | $229.09 |