- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $208.93 / $398.11
| Facility | | $114.82 | $208.93 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $141.25 / $288.40
| Professional | | $79.43 | $141.25 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $416.87
| Facility | | $234.42 | $234.42 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $158.49 / $257.04
| Professional | | $77.62 | $158.49 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $309.03 / $371.54
| Professional | | $158.49 | $309.03 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $141.25 / $316.23
| Facility | | $114.82 | $141.25 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $158.49 / $208.93
| Professional | | $141.25 | $158.49 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $158.49
| Facility | | $141.25 | $141.25 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Professional | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $204.17 / $416.87
| Facility | | $141.25 | $204.17 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $158.49 / $213.80
| Professional | | $141.25 | $158.49 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $363.08 / $562.34
| Facility | | $213.80 | $363.08 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $120.23 / $169.82
| Professional | | $112.20 | $120.23 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $213.80 / $229.09
| Facility | | $169.82 | $213.80 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $190.55
| Professional | | $66.07 | $66.07 | $190.55 |