- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $134.90
| Facility | | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $134.90 / $933.25
| Professional | | $67.61 | $134.90 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $204.17 / $208.93
| Professional | | $186.21 | $204.17 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $239.88
| Facility | | $151.36 | $151.36 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $295.12 / $407.38
| Professional | | $151.36 | $295.12 | $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
- $70.79 / $107.15 / $223.87
| Professional | | $70.79 | $107.15 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $575.44
| Professional | | $234.42 | $234.42 | $575.44 |
- 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
- $295.12 / $537.03 / $575.44
| Professional | | $295.12 | $537.03 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $123.03 / $245.47
| Facility | | $81.28 | $123.03 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $107.15 / $162.18
| Professional | | $77.62 | $107.15 | $162.18 |