- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $316.23
| Facility | | $109.65 | $109.65 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $316.23 / $2,089.30
| Professional | | $199.53 | $316.23 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $478.63 / $478.63
| Professional | | $436.52 | $478.63 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $562.34
| Facility | | $275.42 | $275.42 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $575.44 / $851.14
| Professional | | $275.42 | $575.44 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $549.54 / $2,344.23
| Facility | | $316.23 | $549.54 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $245.47 / $524.81
| Professional | | $165.96 | $245.47 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $1,318.26
| Professional | | $549.54 | $549.54 | $1,318.26 |
- 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
- $691.83 / $1,230.27 / $1,318.26
| Professional | | $691.83 | $1,230.27 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $263.03 / $512.86
| Facility | | $169.82 | $263.03 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $245.47 / $389.05
| Professional | | $177.83 | $245.47 | $389.05 |