- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $120.23 / $199.53
| Professional | | $60.26 | $120.23 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $363.08
| Professional | | $162.18 | $162.18 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $18.20 / $134.90 / $169.82
| Facility | | $18.20 | $134.90 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.20 / $134.90 / $169.82
| Professional | | $18.20 | $134.90 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $134.90
| Facility | | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $134.90 / $162.18
| Professional | | $114.82 | $134.90 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $467.74
| Facility | | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $138.04 / $208.93
| Professional | | $107.15 | $138.04 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $128.82 / $169.82
| Professional | | $120.23 | $128.82 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $8.51 / $70.79 / $123.03
| Facility | | $8.51 | $70.79 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $120.23 / $234.42
| Professional | | $70.79 | $120.23 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $120.23
| Facility | | $117.49 | $117.49 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $169.82
| Professional | | $120.23 | $120.23 | $169.82 |