- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $112.20 / $112.20
| Facility | | $107.15 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $109.65 / $131.83
| Professional | | $107.15 | $109.65 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $245.47 / $302.00
| Facility | | $190.55 | $245.47 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $47.86 / $117.49
| Professional | | $38.90 | $47.86 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $107.15 / $199.53
| Professional | | $91.20 | $107.15 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $74.13 / $117.49
| Facility | | $45.71 | $74.13 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $64.57 / $117.49
| Professional | | $53.70 | $64.57 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $53.70 / $117.49
| Professional | | $45.71 | $53.70 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $245.47 / $302.00
| Facility | | $204.17 | $245.47 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $117.49 / $117.49
| Professional | | $57.54 | $117.49 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.04 / $38.02 / $63.10
| Facility | | $0.04 | $38.02 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $125.89 / $131.83
| Professional | | $38.02 | $125.89 | $131.83 |
- 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
- $107.15 / $107.15 / $107.15
| Professional | | $107.15 | $107.15 | $107.15 |