- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $288.40 / $660.69
| Facility | | $173.78 | $288.40 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $128.82 / $660.69
| Professional | | $93.33 | $128.82 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $489.78
| Facility | | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $323.59 / $407.38
| Professional | | $117.49 | $323.59 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $234.42 / $407.38
| Professional | | $131.83 | $234.42 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $213.80 / $575.44
| Facility | | $112.20 | $213.80 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $199.53 / $741.31
| Professional | | $123.03 | $199.53 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $251.19 / $346.74
| Professional | | $218.78 | $251.19 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $489.78
| Facility | | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $295.12 / $346.74
| Professional | | $199.53 | $295.12 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $190.55 / $245.47
| Facility | | $109.65 | $190.55 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $173.78 / $338.84
| Professional | | $117.49 | $173.78 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $281.84
| Professional | | $239.88 | $239.88 | $281.84 |