- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $229.09 / $281.84
| Professional | | $131.83 | $229.09 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $389.05 / $724.44
| Facility | | $288.40 | $389.05 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $218.78 / $229.09
| Professional | | $204.17 | $218.78 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $208.93 / $346.74
| Professional | | $85.11 | $208.93 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $275.42 / $426.58
| Facility | | $112.20 | $275.42 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $354.81 / $1,258.93
| Professional | | $112.20 | $354.81 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $575.44
| Professional | | $257.04 | $257.04 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $218.78 / $575.44
| Professional | | $194.98 | $218.78 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $181.97
| Professional | | $131.83 | $131.83 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $309.03 / $588.84
| Facility | | $223.87 | $309.03 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $302.00 / $562.34
| Professional | | $123.03 | $302.00 | $562.34 |