- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $239.88 / $239.88
| Facility | | $87.10 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $87.10 / $239.88
| Professional | | $85.11 | $87.10 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $112.20 / $239.88
| Professional | | $89.13 | $112.20 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $1,071.52 / $1,698.24
| Professional | | $95.50 | $1,071.52 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $177.83 / $1,995.26
| Facility | | $107.15 | $177.83 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $120.23 / $5,888.44
| Professional | | $107.15 | $120.23 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $190.55 / $831.76
| Professional | | $162.18 | $190.55 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $1,548.82 / $2,884.03
| Professional | | $295.12 | $1,548.82 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $186.21 / $257.04
| Professional | | $93.33 | $186.21 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $257.04
| Facility | | $120.23 | $120.23 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $93.33 / $169.82
| Professional | | $87.10 | $93.33 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $104.71
| Facility | | $95.50 | $95.50 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $95.50 / $104.71
| Professional | | $75.86 | $95.50 | $104.71 |