- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $165.96 / $281.84
| Facility | | $131.83 | $165.96 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $281.84
| Professional | | $162.18 | $162.18 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $309.03 / $851.14
| Facility | | $177.83 | $309.03 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $177.83 / $288.40
| Professional | | $154.88 | $177.83 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $190.55
| Professional | | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $416.87 / $489.78
| Facility | | $363.08 | $416.87 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Professional | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Facility | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $245.47
| Professional | | $162.18 | $162.18 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $181.97 / $229.09
| Professional | | $141.25 | $181.97 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $181.97 / $380.19
| Professional | | $154.88 | $181.97 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $165.96 / $302.00
| Facility | | $102.33 | $165.96 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $165.96 / $181.97
| Professional | | $138.04 | $165.96 | $181.97 |