- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $128.82
| Facility | | $109.65 | $109.65 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $131.83
| Professional | | $109.65 | $109.65 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $117.49 / $123.03
| Facility | | $93.33 | $117.49 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $123.03
| Professional | | $117.49 | $117.49 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $208.93 / $229.09
| Facility | | $144.54 | $208.93 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $208.93 / $316.23
| Professional | | $125.89 | $208.93 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $190.55 / $263.03
| Facility | | $128.82 | $190.55 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $457.09
| Professional | | $128.82 | $128.82 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $245.47 / $398.11
| Professional | | $147.91 | $245.47 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $208.93 / $309.03
| Facility | | $169.82 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $323.59 / $398.11
| Professional | | $302.00 | $323.59 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $251.19 / $549.54
| Facility | | $102.33 | $251.19 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $141.25 / $229.09
| Professional | | $125.89 | $141.25 | $229.09 |