- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $239.88
| Facility | | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $239.88 / $1,737.80
| Professional | | $97.72 | $239.88 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $371.54 / $371.54
| Professional | | $331.13 | $371.54 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $186.21 / $426.58
| Facility | | $186.21 | $186.21 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $416.87 / $645.65
| Professional | | $186.21 | $416.87 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $416.87 / $1,621.81
| Facility | | $239.88 | $416.87 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $177.83 / $380.19
| Professional | | $125.89 | $177.83 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $1,023.29
| Professional | | $416.87 | $416.87 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $426.58
| Facility | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $954.99 / $1,023.29
| Professional | | $524.81 | $954.99 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $177.83 / $346.74
| Facility | | $114.82 | $177.83 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $181.97 / $295.12
| Professional | | $125.89 | $181.97 | $295.12 |