- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $208.93 / $295.12
| Professional | | $177.83 | $208.93 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $245.47 / $371.54
| Facility | | $173.78 | $245.47 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $295.12 / $331.13
| Professional | | $251.19 | $295.12 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $309.03 / $371.54
| Facility | | $147.91 | $309.03 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $346.74 / $524.81
| Professional | | $316.23 | $346.74 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $245.47 / $407.38
| Facility | | $190.55 | $245.47 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $223.87 / $371.54
| Professional | | $177.83 | $223.87 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $77.62
| Professional | | $30.20 | $30.20 | $77.62 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $281.84 / $371.54
| Facility | | $199.53 | $281.84 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $295.12 / $380.19
| Professional | | $251.19 | $295.12 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $173.78 / $275.42
| Professional | | $125.89 | $173.78 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $109.65
| Facility | | $85.11 | $85.11 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $114.82 / $223.87
| Professional | | $95.50 | $114.82 | $223.87 |