- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $229.09
| Facility | | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $229.09 / $1,659.59
| Professional | | $91.20 | $229.09 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $346.74 / $354.81
| Professional | | $316.23 | $346.74 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $407.38
| Facility | | $223.87 | $223.87 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $446.68 / $616.60
| Professional | | $223.87 | $446.68 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $389.05 / $1,548.82
| Facility | | $229.09 | $389.05 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $169.82 / $363.08
| Professional | | $120.23 | $169.82 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $977.24
| Professional | | $398.11 | $398.11 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $407.38 / $407.38
| Facility | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $912.01 / $977.24
| Professional | | $501.19 | $912.01 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $169.82 / $331.13
| Facility | | $109.65 | $169.82 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $169.82 / $275.42
| Professional | | $120.23 | $169.82 | $275.42 |