- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $316.23
| Facility | | $208.93 | $208.93 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $181.97 / $316.23
| Professional | | $147.91 | $181.97 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $416.87
| Facility | | $309.03 | $309.03 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $331.13 / $426.58
| Professional | | $309.03 | $331.13 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $467.74 / $501.19
| Professional | | $251.19 | $467.74 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $478.63 / $1,258.93
| Facility | | $218.78 | $478.63 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $295.12 / $741.31
| Professional | | $208.93 | $295.12 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $436.52 / $977.24
| Professional | | $407.38 | $436.52 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $416.87
| Facility | | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $741.31 / $741.31
| Professional | | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $346.74 / $1,023.29
| Facility | | $165.96 | $346.74 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $218.78 / $380.19
| Professional | | $204.17 | $218.78 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $363.08 / $363.08
| Professional | | $281.84 | $363.08 | $363.08 |