- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $501.19 / $575.44
| Facility | | $288.40 | $501.19 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $251.19 / $489.78
| Professional | | $186.21 | $251.19 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $1,047.13
| Facility | | $295.12 | $295.12 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $181.97 / $524.81
| Professional | | $117.49 | $181.97 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $426.58 / $776.25
| Facility | | $407.38 | $426.58 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $295.12 / $501.19
| Professional | | $208.93 | $295.12 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $575.44 / $1,202.26
| Facility | | $208.93 | $575.44 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $151.36 / $398.11
| Professional | | $125.89 | $151.36 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $371.54 / $1,412.54
| Facility | | $257.04 | $371.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $177.83 / $1,479.11
| Professional | | $123.03 | $177.83 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $295.12 / $354.81
| Facility | | $123.03 | $295.12 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $177.83 / $398.11
| Professional | | $123.03 | $177.83 | $398.11 |