- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $851.14 / $912.01
| Facility | | $169.82 | $851.14 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $190.55 / $295.12
| Professional | | $151.36 | $190.55 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $281.84 / $457.09
| Professional | | $69.18 | $281.84 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $229.09 / $436.52
| Professional | | $151.36 | $229.09 | $436.52 |
- 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
- $154.88 / $213.80 / $346.74
| Facility | | $154.88 | $213.80 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $467.74
| Professional | | $89.13 | $89.13 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $263.03 / $338.84
| Professional | | $74.13 | $263.03 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $295.12
| Facility | | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $190.55 / $295.12
| Professional | | $147.91 | $190.55 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,122.02
| Facility | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,380.38
| Professional | | $1,122.02 | $1,122.02 | $1,380.38 |