- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $269.15
| Facility | | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $309.03 / $478.63
| Professional | | $245.47 | $309.03 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $416.87 / $501.19
| Professional | | $371.54 | $416.87 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $549.54 / $645.65
| Professional | | $316.23 | $549.54 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $363.08 / $398.11
| Facility | | $245.47 | $363.08 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $741.31
| Professional | | $263.03 | $263.03 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $309.03
| Professional | | $257.04 | $257.04 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $389.05 / $870.96
| Facility | | $251.19 | $389.05 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $165.96
| Professional | | $162.18 | $162.18 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $371.54
| Professional | | $30.20 | $30.20 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $323.59 / $691.83
| Facility | | $194.98 | $323.59 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $269.15 / $363.08
| Professional | | $208.93 | $269.15 | $363.08 |