- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $489.78
| Facility | | $239.88 | $239.88 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $257.04 / $489.78
| Professional | | $194.98 | $257.04 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $933.25 / $3,311.31
| Facility | | $575.44 | $933.25 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $489.78
| Facility | | $309.03 | $309.03 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $489.78
| Professional | | $229.09 | $229.09 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $549.54 / $676.08
| Professional | | $407.38 | $549.54 | $676.08 |
- 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
- $630.96 / $630.96 / $630.96
| Professional | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $389.05
| Professional | | $269.15 | $269.15 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $389.05 / $707.95
| Facility | | $288.40 | $389.05 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $239.88 / $398.11
| Professional | | $186.21 | $239.88 | $398.11 |