- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $181.97
| Facility | | $134.90 | $134.90 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $165.96 / $389.05
| Professional | | $125.89 | $165.96 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $371.54 / $457.09
| Professional | | $363.08 | $371.54 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $208.93 / $776.25
| Professional | | $131.83 | $208.93 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $416.87 / $1,202.26
| Facility | | $208.93 | $416.87 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $251.19 / $524.81
| Professional | | $154.88 | $251.19 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $380.19 / $501.19
| Professional | | $302.00 | $380.19 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $398.11
| Professional | | $363.08 | $363.08 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $870.96 / $1,122.02
| Facility | | $512.86 | $870.96 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $181.97 / $380.19
| Professional | | $158.49 | $181.97 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $263.03 / $309.03
| Professional | | $208.93 | $263.03 | $309.03 |