- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Facility | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $109.65 / $616.60
| Professional | | $77.62 | $109.65 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $158.49 / $223.87
| Professional | | $77.62 | $158.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $144.54 / $524.81
| Professional | | $83.18 | $144.54 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $138.04 / $239.88
| Facility | | $81.28 | $138.04 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $162.18 / $741.31
| Professional | | $87.10 | $162.18 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $194.98 / $223.87
| Professional | | $123.03 | $194.98 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $173.78 / $223.87
| Professional | | $125.89 | $173.78 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $141.25 / $181.97
| Professional | | $77.62 | $141.25 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $72.44
| Facility | | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $125.89 / $218.78
| Professional | | $83.18 | $125.89 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $158.49 / $186.21
| Professional | | $125.89 | $158.49 | $186.21 |