- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $83.18 / $117.49
| Professional | | $61.66 | $83.18 | $117.49 |
- 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
- $74.13 / $74.13 / $74.13
| Professional | | $74.13 | $74.13 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $316.23 / $380.19
| Professional | | $134.90 | $316.23 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $134.90 / $177.83
| Facility | | $104.71 | $134.90 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $141.25 / $190.55
| Professional | | $128.82 | $141.25 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $173.78 / $177.83
| Facility | | $141.25 | $173.78 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $177.83 / $186.21
| Professional | | $158.49 | $177.83 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $144.54 / $199.53
| Facility | | $89.13 | $144.54 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $151.36 / $186.21
| Professional | | $74.13 | $151.36 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $281.84 / $691.83
| Facility | | $147.91 | $281.84 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $199.53 / $199.53
| Professional | | $177.83 | $199.53 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $91.20 / $229.09
| Facility | | $64.57 | $91.20 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $70.79 / $134.90
| Professional | | $57.54 | $70.79 | $134.90 |