- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $141.25 / $1,288.25
| Professional | | $70.79 | $141.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $213.80 / $218.78
| Professional | | $194.98 | $213.80 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $251.19
| Facility | | $181.97 | $181.97 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $309.03 / $426.58
| Professional | | $181.97 | $309.03 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $251.19 / $1,174.90
| Facility | | $141.25 | $251.19 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $138.04 / $223.87
| Professional | | $74.13 | $138.04 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $245.47 / $602.56
| Professional | | $245.47 | $245.47 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $549.54 / $602.56
| Professional | | $309.03 | $549.54 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $169.82 / $257.04
| Facility | | $147.91 | $169.82 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $109.65 / $173.78
| Professional | | $81.28 | $109.65 | $173.78 |