- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $53.70
| Facility | | $53.70 | $53.70 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $81.28 / $95.50
| Professional | | $53.70 | $81.28 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $151.36 / $407.38
| Professional | | $89.13 | $151.36 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $81.28 / $169.82
| Facility | | $51.29 | $81.28 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $83.18 / $426.58
| Facility | | $54.95 | $83.18 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $154.88 / $524.81
| Professional | | $89.13 | $154.88 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $64.57 / $70.79
| Professional | | $50.12 | $64.57 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $229.09 / $323.59
| Professional | | $131.83 | $229.09 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $524.81 / $524.81
| Facility | | $223.87 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $524.81 / $524.81
| Professional | | $407.38 | $524.81 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $588.84 / $1,202.26
| Facility | | $91.20 | $588.84 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $128.82 / $302.00
| Professional | | $87.10 | $128.82 | $302.00 |