- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $213.80 / $269.15
| Facility | | $199.53 | $213.80 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $169.82 / $251.19
| Professional | | $123.03 | $169.82 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $309.03
| Facility | | $169.82 | $169.82 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $371.54 / $467.74
| Professional | | $169.82 | $371.54 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $371.54 / $446.68
| Professional | | $263.03 | $371.54 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $363.08 / $1,445.44
| Facility | | $186.21 | $363.08 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $194.98 / $467.74
| Professional | | $134.90 | $194.98 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $316.23 / $416.87
| Professional | | $302.00 | $316.23 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $309.03
| Facility | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $457.09 / $457.09
| Professional | | $457.09 | $457.09 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $281.84 / $724.44
| Facility | | $134.90 | $281.84 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $154.88 / $263.03
| Professional | | $134.90 | $154.88 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $269.15 / $269.15
| Professional | | $213.80 | $269.15 | $269.15 |