- 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
- $67.61 / $87.10 / $138.04
| Professional | | $67.61 | $87.10 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $97.72
| Facility | | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $70.79
| Professional | | $70.79 | $70.79 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $323.59 / $389.05
| Professional | | $134.90 | $323.59 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $134.90 / $181.97
| Facility | | $107.15 | $134.90 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $141.25 / $199.53
| Professional | | $131.83 | $141.25 | $199.53 |
- 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 / $194.98
| Professional | | $158.49 | $177.83 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $147.91 / $199.53
| Facility | | $89.13 | $147.91 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $154.88 / $186.21
| Professional | | $70.79 | $154.88 | $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
- $89.13 / $109.65 / $239.88
| Facility | | $89.13 | $109.65 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $72.44 / $138.04
| Professional | | $64.57 | $72.44 | $138.04 |