- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $346.74 / $691.83
| Professional | | $223.87 | $346.74 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $436.52 / $660.69
| Professional | | $323.59 | $436.52 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $380.19 / $691.83
| Professional | | $346.74 | $380.19 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $575.44
| Facility | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $371.54 / $645.65
| Professional | | $288.40 | $371.54 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $436.52 / $616.60
| Professional | | $363.08 | $436.52 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $416.87 / $489.78
| Professional | | $338.84 | $416.87 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $407.38 / $616.60
| Facility | | $302.00 | $407.38 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Professional | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $363.08 / $602.56
| Facility | | $302.00 | $363.08 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $363.08 / $602.56
| Professional | | $302.00 | $363.08 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Facility | | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $331.13 / $524.81
| Professional | | $229.09 | $331.13 | $524.81 |