- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $501.19 / $501.19
| Facility | | $93.33 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $295.12 / $426.58
| Professional | | $199.53 | $295.12 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $467.74 / $794.33
| Facility | | $354.81 | $467.74 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $549.54 / $549.54
| Professional | | $512.86 | $549.54 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $302.00
| Facility | | $275.42 | $275.42 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $275.42
| Professional | | $204.17 | $204.17 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $467.74 / $537.03
| Facility | | $144.54 | $467.74 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $446.68 / $501.19
| Professional | | $288.40 | $446.68 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $416.87
| Professional | | $30.20 | $30.20 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $478.63 / $478.63
| Facility | | $467.74 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $524.81
| Professional | | $346.74 | $346.74 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $501.19 / $512.86
| Professional | | $389.05 | $501.19 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $257.04 / $288.40
| Facility | | $218.78 | $257.04 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $223.87 / $338.84
| Professional | | $204.17 | $223.87 | $338.84 |