- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $131.83 / $1,230.27
| Professional | | $67.61 | $131.83 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $204.17 / $204.17
| Professional | | $186.21 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $234.42
| Facility | | $141.25 | $141.25 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $251.19 / $407.38
| Professional | | $141.25 | $251.19 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $239.88 / $1,096.48
| Facility | | $134.90 | $239.88 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $104.71 / $208.93
| Professional | | $69.18 | $104.71 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $562.34
| Professional | | $229.09 | $229.09 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $234.42
| Facility | | $234.42 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $524.81 / $562.34
| Professional | | $288.40 | $524.81 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $125.89 / $245.47
| Facility | | $81.28 | $125.89 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $104.71 / $165.96
| Professional | | $75.86 | $104.71 | $165.96 |