- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $239.88 / $398.11
| Facility | | $141.25 | $239.88 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $288.40 / $478.63
| Professional | | $229.09 | $288.40 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $426.58 / $851.14
| Professional | | $354.81 | $426.58 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $524.81 / $562.34
| Professional | | $416.87 | $524.81 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $870.96
| Facility | | $338.84 | $338.84 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $245.47 / $338.84
| Professional | | $245.47 | $245.47 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $338.84 / $562.34
| Professional | | $123.03 | $338.84 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $288.40 / $363.08
| Professional | | $186.21 | $288.40 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $245.47 / $660.69
| Facility | | $186.21 | $245.47 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $269.15 / $346.74
| Professional | | $218.78 | $269.15 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $562.34
| Professional | | $288.40 | $288.40 | $562.34 |