- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $208.93
| Facility | | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $208.93 / $295.12
| Professional | | $165.96 | $208.93 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $354.81 / $426.58
| Facility | | $354.81 | $354.81 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $102.33
| Professional | | $70.79 | $70.79 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $223.87 / $346.74
| Facility | | $87.10 | $223.87 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $138.04 / $245.47
| Professional | | $91.20 | $138.04 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Professional | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $208.93 / $323.59
| Facility | | $89.13 | $208.93 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $691.83
| Professional | | $109.65 | $109.65 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $131.83 / $131.83
| Professional | | $123.03 | $131.83 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $186.21 / $346.74
| Facility | | $181.97 | $186.21 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $229.09 / $407.38
| Professional | | $100.00 | $229.09 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $616.60
| Facility | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,258.93 / $1,258.93
| Professional | | $1,258.93 | $1,258.93 | $1,258.93 |