- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $263.03
| Facility | | $263.03 | $263.03 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $245.47 / $467.74
| Professional | | $120.23 | $245.47 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $239.88 / $263.03
| Professional | | $229.09 | $239.88 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $758.58 / $3,311.31
| Facility | | $645.65 | $758.58 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $218.78 / $295.12
| Professional | | $128.82 | $218.78 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $251.19 / $436.52
| Professional | | $131.83 | $251.19 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $194.98 / $263.03
| Facility | | $114.82 | $194.98 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $251.19 / $1,348.96
| Professional | | $169.82 | $251.19 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $281.84 / $371.54
| Professional | | $204.17 | $281.84 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $281.84 / $346.74
| Professional | | $229.09 | $281.84 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $302.00 / $354.81
| Professional | | $269.15 | $302.00 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.15 / $0.15 / $0.15
| Facility | | $0.15 | $0.15 | $0.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $229.09 / $354.81
| Professional | | $147.91 | $229.09 | $354.81 |