- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $288.40
| Facility | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $302.00 / $512.86
| Professional | | $251.19 | $302.00 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $380.19
| Professional | | $380.19 | $380.19 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $616.60 / $741.31
| Professional | | $588.84 | $616.60 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $363.08
| Facility | | $323.59 | $323.59 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $676.08
| Professional | | $239.88 | $239.88 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Professional | | $85.11 | $85.11 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $354.81 / $870.96
| Facility | | $125.89 | $354.81 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $380.19
| Professional | | $165.96 | $165.96 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $398.11
| Professional | | $30.20 | $30.20 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $309.03 / $707.95
| Facility | | $199.53 | $309.03 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $288.40 / $416.87
| Professional | | $218.78 | $288.40 | $416.87 |