- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Facility | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $89.13 / $398.11
| Professional | | $77.62 | $89.13 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $151.36 / $204.17
| Professional | | $91.20 | $151.36 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $109.65 / $199.53
| Professional | | $77.62 | $109.65 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $100.00 / $151.36
| Facility | | $83.18 | $100.00 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $85.11 / $147.91
| Professional | | $64.57 | $85.11 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $758.58
| Professional | | $575.44 | $575.44 | $758.58 |