- 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
- $54.95 / $100.00 / $107.15
| Professional | | $54.95 | $100.00 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $144.54
| Professional | | $123.03 | $123.03 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $407.38 / $562.34
| Facility | | $346.74 | $407.38 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $186.21 / $251.19
| Professional | | $58.88 | $186.21 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $109.65 / $128.82
| Facility | | $95.50 | $109.65 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $120.23 / $158.49
| Professional | | $109.65 | $120.23 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $120.23 / $199.53
| Facility | | $95.50 | $120.23 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $61.66 / $120.23
| Professional | | $47.86 | $61.66 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $50.12 / $70.79
| Professional | | $32.36 | $50.12 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $128.82 / $199.53
| Professional | | $97.72 | $128.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $199.53 / $363.08
| Professional | | $131.83 | $199.53 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $630.96
| Facility | | $263.03 | $263.03 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $588.84 / $741.31
| Professional | | $58.88 | $588.84 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $60.26 / $97.72
| Professional | | $42.66 | $60.26 | $97.72 |