- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $169.82
| Facility | | $109.65 | $109.65 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $109.65 / $138.04
| Professional | | $81.28 | $109.65 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $194.98
| Professional | | $162.18 | $162.18 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $173.78 / $275.42
| Professional | | $114.82 | $173.78 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Facility | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $158.49
| Professional | | $134.90 | $134.90 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $125.89 / $204.17
| Facility | | $100.00 | $125.89 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $50.12 / $275.42
| Professional | | $50.12 | $50.12 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $190.55 / $213.80
| Professional | | $0.60 | $190.55 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Facility | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $123.03 / $204.17
| Professional | | $93.33 | $123.03 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $691.83 / $691.83
| Facility | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $691.83 / $870.96
| Professional | | $691.83 | $691.83 | $870.96 |