- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Facility | | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $104.71 / $204.17
| Professional | | $89.13 | $104.71 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $295.12
| Facility | | $251.19 | $251.19 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $177.83 / $239.88
| Professional | | $104.71 | $177.83 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $208.93 / $354.81
| Professional | | $109.65 | $208.93 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $158.49 / $208.93
| Facility | | $95.50 | $158.49 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $208.93 / $1,071.52
| Professional | | $134.90 | $208.93 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $229.09 / $302.00
| Professional | | $165.96 | $229.09 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $229.09 / $281.84
| Professional | | $186.21 | $229.09 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $234.42 / $295.12
| Professional | | $194.98 | $234.42 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.13 / $0.13 / $0.13
| Facility | | $0.13 | $0.13 | $0.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $190.55 / $288.40
| Professional | | $123.03 | $190.55 | $288.40 |