- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $109.65 / $123.03
| Professional | | $52.48 | $109.65 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $147.91
| Professional | | $123.03 | $123.03 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $407.38 / $562.34
| Facility | | $354.81 | $407.38 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $190.55 / $251.19
| Professional | | $63.10 | $190.55 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $109.65 / $131.83
| Facility | | $95.50 | $109.65 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $158.49 / $346.74
| Professional | | $117.49 | $158.49 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $123.03 / $204.17
| Facility | | $95.50 | $123.03 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $64.57 / $123.03
| Professional | | $50.12 | $64.57 | $123.03 |
- 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 / $131.83 / $204.17
| Professional | | $97.72 | $131.83 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $199.53 / $389.05
| Professional | | $131.83 | $199.53 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $812.83
| Facility | | $263.03 | $263.03 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $588.84 / $1,047.13
| Professional | | $61.66 | $588.84 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $64.57 / $97.72
| Professional | | $50.12 | $64.57 | $97.72 |