- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $138.04 / $1,071.52
| Professional | | $69.18 | $138.04 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $234.42 / $234.42
| Professional | | $213.80 | $234.42 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $269.15
| Facility | | $134.90 | $134.90 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $281.84 / $416.87
| Professional | | $134.90 | $281.84 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $263.03 / $1,122.02
| Facility | | $154.88 | $263.03 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $120.23 / $234.42
| Professional | | $79.43 | $120.23 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $645.65
| Professional | | $263.03 | $263.03 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $269.15
| Facility | | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $602.56 / $645.65
| Professional | | $331.13 | $602.56 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $128.82 / $251.19
| Facility | | $83.18 | $128.82 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $120.23 / $190.55
| Professional | | $87.10 | $120.23 | $190.55 |