- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Facility | | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $100.00 / $104.71
| Professional | | $95.50 | $100.00 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $251.19 / $467.74
| Professional | | $151.36 | $251.19 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $199.53 / $389.05
| Facility | | $169.82 | $199.53 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $147.91 / $181.97
| Professional | | $125.89 | $147.91 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $102.33 / $147.91
| Facility | | $97.72 | $102.33 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $120.23 / $239.88
| Facility | | $97.72 | $120.23 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $457.09
| Professional | | $100.00 | $100.00 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $54.95 / $70.79
| Professional | | $32.36 | $54.95 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Facility | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $295.12 / $416.87
| Professional | | $141.25 | $295.12 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $363.08
| Facility | | $102.33 | $102.33 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $549.54
| Professional | | $102.33 | $102.33 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $190.55 / $338.84
| Professional | | $147.91 | $190.55 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $281.84
| Facility | | $120.23 | $120.23 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $125.89 / $134.90
| Professional | | $100.00 | $125.89 | $134.90 |