- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $1,148.15
| Facility | | $162.18 | $162.18 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $186.21 / $309.03
| Professional | | $186.21 | $186.21 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $245.47 / $363.08
| Professional | | $213.80 | $245.47 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $416.87 / $537.03
| Facility | | $223.87 | $416.87 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $213.80 / $213.80
| Professional | | $186.21 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $194.98 / $229.09
| Professional | | $162.18 | $194.98 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $251.19
| Professional | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $190.55 / $251.19
| Facility | | $151.36 | $190.55 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $213.80 / $323.59
| Facility | | $208.93 | $213.80 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $213.80 / $323.59
| Professional | | $208.93 | $213.80 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $257.04 / $338.84
| Facility | | $204.17 | $257.04 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $208.93 / $218.78
| Professional | | $162.18 | $208.93 | $218.78 |