- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $131.83 / $186.21
| Professional | | $104.71 | $131.83 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $269.15
| Facility | | $257.04 | $257.04 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $275.42
| Professional | | $134.90 | $134.90 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $173.78
| Professional | | $134.90 | $134.90 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $138.04 / $138.04
| Facility | | $100.00 | $138.04 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $138.04
| Professional | | $102.33 | $102.33 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $257.04 / $354.81
| Professional | | $190.55 | $257.04 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $165.96 / $251.19
| Professional | | $134.90 | $165.96 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $169.82 / $316.23
| Facility | | $93.33 | $169.82 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $144.54 / $165.96
| Professional | | $138.04 | $144.54 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $208.93 / $741.31
| Facility | | $144.54 | $208.93 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $208.93 / $741.31
| Professional | | $144.54 | $208.93 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $165.96 / $257.04
| Facility | | $85.11 | $165.96 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $125.89 / $199.53
| Professional | | $112.20 | $125.89 | $199.53 |