- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $316.23
| Facility | | $204.17 | $204.17 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $204.17 / $288.40
| Professional | | $131.83 | $204.17 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $363.08
| Facility | | $269.15 | $269.15 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $478.63 / $588.84
| Professional | | $269.15 | $478.63 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $363.08 / $407.38
| Professional | | $309.03 | $363.08 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $416.87 / $1,698.24
| Facility | | $218.78 | $416.87 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $208.93 / $537.03
| Professional | | $154.88 | $208.93 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $371.54 / $489.78
| Professional | | $354.81 | $371.54 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $363.08
| Facility | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $537.03 / $537.03
| Professional | | $371.54 | $537.03 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $331.13 / $851.14
| Facility | | $123.03 | $331.13 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $162.18 / $338.84
| Professional | | $147.91 | $162.18 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $316.23 / $316.23
| Professional | | $251.19 | $316.23 | $316.23 |