- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $204.17
| Facility | | $89.13 | $89.13 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $107.15 / $263.03
| Professional | | $83.18 | $107.15 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $407.38 / $407.38
| Facility | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $251.19 / $309.03
| Professional | | $239.88 | $251.19 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $169.82 / $616.60
| Professional | | $102.33 | $169.82 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $398.11 / $1,202.26
| Facility | | $199.53 | $398.11 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $199.53 / $524.81
| Professional | | $104.71 | $199.53 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $239.88 / $537.03
| Professional | | $199.53 | $239.88 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $407.38 / $407.38
| Facility | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $245.47 / $257.04
| Professional | | $245.47 | $245.47 | $257.04 |
- 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
- $100.00 / $128.82 / $251.19
| Professional | | $100.00 | $128.82 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $177.83 / $208.93
| Professional | | $141.25 | $177.83 | $208.93 |