- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $309.03 / $426.58
| Facility | | $181.97 | $309.03 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $309.03 / $338.84
| Professional | | $263.03 | $309.03 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $288.40 / $562.34
| Facility | | $114.82 | $288.40 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $138.04
| Professional | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $676.08 / $1,949.84
| Facility | | $288.40 | $676.08 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $288.40
| Professional | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $933.25 / $933.25
| Facility | | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $309.03 / $436.52
| Facility | | $79.43 | $309.03 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $309.03 / $416.87
| Professional | | $263.03 | $309.03 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $323.59 / $891.25
| Facility | | $120.23 | $323.59 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $288.40
| Professional | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $288.40 / $288.40
| Facility | | $213.80 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $302.00 / $309.03
| Professional | | $245.47 | $302.00 | $309.03 |