- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $134.90
| Facility | | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $64.57 / $128.82
| Professional | | $56.23 | $64.57 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $181.97
| Facility | | $154.88 | $154.88 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $112.20 / $147.91
| Professional | | $66.07 | $112.20 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $131.83 / $229.09
| Professional | | $69.18 | $131.83 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $102.33 / $138.04
| Facility | | $60.26 | $102.33 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $134.90 / $467.74
| Professional | | $87.10 | $134.90 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $147.91 / $194.98
| Professional | | $104.71 | $147.91 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $144.54 / $177.83
| Professional | | $120.23 | $144.54 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $147.91 / $186.21
| Professional | | $141.25 | $147.91 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.08 / $0.08 / $0.08
| Facility | | $0.08 | $0.08 | $0.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $125.89 / $181.97
| Professional | | $79.43 | $125.89 | $181.97 |