- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Facility | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $104.71 / $138.04
| Professional | | $83.18 | $104.71 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $467.74 / $630.96
| Facility | | $416.87 | $467.74 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $162.18 / $223.87
| Professional | | $95.50 | $162.18 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $134.90 / $257.04
| Professional | | $104.71 | $134.90 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $154.88 / $234.42
| Facility | | $100.00 | $154.88 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $199.53 / $691.83
| Professional | | $104.71 | $199.53 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $177.83 / $269.15
| Professional | | $144.54 | $177.83 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $186.21 / $269.15
| Professional | | $134.90 | $186.21 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $204.17 / $269.15
| Professional | | $112.20 | $204.17 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.11 / $0.11 / $0.11
| Facility | | $0.11 | $0.11 | $0.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $190.55 / $257.04
| Professional | | $114.82 | $190.55 | $257.04 |