- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Facility | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $158.49 / $1,122.02
| Professional | | $83.18 | $158.49 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $239.88 / $239.88
| Professional | | $218.78 | $239.88 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $275.42
| Facility | | $125.89 | $125.89 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $269.15 / $416.87
| Professional | | $125.89 | $269.15 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $269.15 / $1,047.13
| Facility | | $158.49 | $269.15 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $120.23 / $218.78
| Professional | | $81.28 | $120.23 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $660.69
| Professional | | $269.15 | $269.15 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $275.42
| Facility | | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $616.60 / $660.69
| Professional | | $338.84 | $616.60 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $120.23 / $234.42
| Facility | | $77.62 | $120.23 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $117.49 / $194.98
| Professional | | $83.18 | $117.49 | $194.98 |