- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $141.25 / $234.42
| Professional | | $123.03 | $141.25 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $288.40
| Facility | | $269.15 | $269.15 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $363.08
| Professional | | $177.83 | $177.83 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $186.21
| Professional | | $144.54 | $144.54 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $165.96 / $165.96
| Facility | | $138.04 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $165.96
| Professional | | $120.23 | $120.23 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $269.15 / $380.19
| Professional | | $204.17 | $269.15 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $177.83 / $269.15
| Professional | | $134.90 | $177.83 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $199.53 / $346.74
| Facility | | $123.03 | $199.53 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $173.78 / $177.83
| Professional | | $144.54 | $173.78 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $223.87 / $794.33
| Facility | | $154.88 | $223.87 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $223.87 / $794.33
| Professional | | $154.88 | $223.87 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $199.53 / $269.15
| Facility | | $102.33 | $199.53 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $138.04 / $208.93
| Professional | | $125.89 | $138.04 | $208.93 |