- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Facility | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $123.03 / $812.83
| Professional | | $54.95 | $123.03 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $186.21 / $186.21
| Professional | | $169.82 | $186.21 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $213.80
| Facility | | $107.15 | $107.15 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $223.87 / $331.13
| Professional | | $107.15 | $223.87 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $208.93 / $891.25
| Facility | | $109.65 | $208.93 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $95.50 / $190.55
| Professional | | $64.57 | $95.50 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $213.80 / $512.86
| Professional | | $208.93 | $213.80 | $512.86 |
- 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
- $269.15 / $478.63 / $512.86
| Professional | | $269.15 | $478.63 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $102.33 / $199.53
| Facility | | $66.07 | $102.33 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $95.50 / $151.36
| Professional | | $69.18 | $95.50 | $151.36 |