- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $323.59 / $489.78
| Facility | | $165.96 | $323.59 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $218.78 / $446.68
| Professional | | $165.96 | $218.78 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $467.74
| Professional | | $295.12 | $295.12 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $758.58 / $2,691.53
| Facility | | $467.74 | $758.58 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $295.12 / $295.12
| Professional | | $218.78 | $295.12 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $416.87
| Facility | | $234.42 | $234.42 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $457.09
| Professional | | $169.82 | $169.82 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $407.38 / $691.83
| Professional | | $346.74 | $407.38 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $512.86 / $512.86
| Professional | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $316.23
| Professional | | $218.78 | $218.78 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $316.23 / $602.56
| Facility | | $154.88 | $316.23 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $194.98 / $512.86
| Professional | | $85.11 | $194.98 | $512.86 |