- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $102.33 / $141.25
| Professional | | $77.62 | $102.33 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Professional | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $380.19 / $467.74
| Professional | | $147.91 | $380.19 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $141.25 / $190.55
| Facility | | $112.20 | $141.25 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $151.36 / $204.17
| Professional | | $138.04 | $151.36 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $181.97 / $190.55
| Facility | | $147.91 | $181.97 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $194.98
| Professional | | $190.55 | $190.55 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $154.88 / $223.87
| Facility | | $102.33 | $154.88 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $165.96 / $199.53
| Professional | | $79.43 | $165.96 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $302.00 / $741.31
| Facility | | $158.49 | $302.00 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $213.80 / $213.80
| Professional | | $190.55 | $213.80 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $109.65 / $281.84
| Facility | | $66.07 | $109.65 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $85.11 / $165.96
| Professional | | $75.86 | $85.11 | $165.96 |