- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $208.93 / $794.33
| Facility | | $102.33 | $208.93 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $125.89 / $288.40
| Professional | | $97.72 | $125.89 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $194.98 / $363.08
| Professional | | $162.18 | $194.98 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $239.88
| Facility | | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $223.87 / $239.88
| Professional | | $177.83 | $223.87 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $371.54
| Facility | | $131.83 | $131.83 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $131.83
| Professional | | $95.50 | $95.50 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $125.89 / $181.97
| Facility | | $87.10 | $125.89 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $144.54 / $239.88
| Professional | | $104.71 | $144.54 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $186.21 / $190.55
| Professional | | $186.21 | $186.21 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $109.65 / $281.84
| Facility | | $79.43 | $109.65 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $114.82 / $147.91
| Professional | | $91.20 | $114.82 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $239.88
| Professional | | $125.89 | $125.89 | $239.88 |