- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Facility | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $173.78
| Professional | | $144.54 | $144.54 | $173.78 |
- 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
- $125.89 / $151.36 / $177.83
| Professional | | $125.89 | $151.36 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $144.54 / $204.17
| Professional | | $93.33 | $144.54 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $162.18 / $223.87
| Facility | | $128.82 | $162.18 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $223.87
| Professional | | $128.82 | $128.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $151.36 / $213.80
| Professional | | $125.89 | $151.36 | $213.80 |
- 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
- $173.78 / $213.80 / $213.80
| Professional | | $173.78 | $213.80 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.14 / $134.90 / $223.87
| Facility | | $0.14 | $134.90 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $138.04
| Professional | | $125.89 | $125.89 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Facility | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Professional | | $144.54 | $144.54 | $144.54 |