- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $109.65 / $223.87
| Professional | | $85.11 | $109.65 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $389.05 / $741.31
| Facility | | $288.40 | $389.05 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $208.93 / $218.78
| Professional | | $190.55 | $208.93 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $239.88 / $338.84
| Professional | | $89.13 | $239.88 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $186.21 / $398.11
| Facility | | $102.33 | $186.21 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $169.82 / $776.25
| Professional | | $107.15 | $169.82 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $239.88 / $380.19
| Professional | | $218.78 | $239.88 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $380.19
| Professional | | $158.49 | $158.49 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $295.12 / $436.52
| Facility | | $70.79 | $295.12 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $169.82 / $257.04
| Professional | | $107.15 | $169.82 | $257.04 |