- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $223.87 / $371.54
| Professional | | $107.15 | $223.87 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $630.96
| Professional | | $208.93 | $208.93 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $239.88 / $323.59
| Facility | | $32.36 | $239.88 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $239.88 / $323.59
| Professional | | $32.36 | $239.88 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $239.88
| Facility | | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $239.88 / $288.40
| Professional | | $204.17 | $239.88 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $263.03 / $398.11
| Professional | | $199.53 | $263.03 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $239.88 / $323.59
| Professional | | $223.87 | $239.88 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $15.14 / $123.03 / $218.78
| Facility | | $15.14 | $123.03 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $223.87 / $446.68
| Professional | | $128.82 | $223.87 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $323.59
| Professional | | $223.87 | $223.87 | $323.59 |