- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $257.04 / $676.08
| Facility | | $144.54 | $257.04 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $74.13 / $645.65
| Professional | | $64.57 | $74.13 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $107.15 / $478.63
| Facility | | $74.13 | $107.15 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $151.36 / $162.18
| Professional | | $104.71 | $151.36 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $186.21 / $234.42
| Professional | | $79.43 | $186.21 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $151.36 / $446.68
| Facility | | $64.57 | $151.36 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $58.88 / $107.15
| Professional | | $41.69 | $58.88 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $204.17
| Professional | | $79.43 | $79.43 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Facility | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $58.88 / $117.49
| Facility | | $41.69 | $58.88 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $58.88 / $107.15
| Professional | | $52.48 | $58.88 | $107.15 |