- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $208.93
| Facility | | $109.65 | $109.65 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $208.93 / $616.60
| Professional | | $128.82 | $208.93 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $245.47 / $501.19
| Professional | | $104.71 | $245.47 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $316.23 / $316.23
| Professional | | $288.40 | $316.23 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $245.47 / $371.54
| Facility | | $218.78 | $245.47 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $389.05 / $588.84
| Professional | | $218.78 | $389.05 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $363.08 / $1,621.81
| Facility | | $208.93 | $363.08 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $331.13
| Professional | | $109.65 | $162.18 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $891.25
| Professional | | $363.08 | $363.08 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $371.54 / $371.54
| Facility | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $812.83 / $891.25
| Professional | | $457.09 | $812.83 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $181.97 / $354.81
| Facility | | $120.23 | $181.97 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $162.18 / $245.47
| Professional | | $117.49 | $162.18 | $245.47 |