- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $123.03 / $123.03
| Facility | | $107.15 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $123.03 / $331.13
| Professional | | $93.33 | $123.03 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $758.58 / $1,819.70
| Facility | | $288.40 | $758.58 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $239.88 / $398.11
| Professional | | $158.49 | $239.88 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $239.88 / $363.08 / $602.56
| Professional | 50 | $239.88 | $363.08 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $426.58 / $1,023.29
| Facility | | $302.00 | $426.58 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $316.23 / $512.86
| Professional | | $194.98 | $316.23 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $407.38 / $812.83
| Facility | | $331.13 | $407.38 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $288.40 / $467.74
| Professional | | $194.98 | $288.40 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $204.17 / $524.81
| Facility | | $120.23 | $204.17 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $213.80 / $812.83
| Professional | | $114.82 | $213.80 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,819.70 / $3,715.35
| Facility | | $1,096.48 | $1,819.70 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $199.53 / $407.38
| Professional | | $114.82 | $199.53 | $407.38 |