- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Facility | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $190.55 / $309.03
| Professional | | $141.25 | $190.55 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $338.84 / $478.63
| Facility | | $323.59 | $338.84 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $295.12 / $524.81
| Professional | | $245.47 | $295.12 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $208.93 / $354.81
| Facility | | $26.30 | $208.93 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $27.54 / $204.17 / $316.23
| Professional | | $27.54 | $204.17 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $275.42
| Facility | | $204.17 | $204.17 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $269.15
| Professional | | $173.78 | $173.78 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $275.42
| Facility | | $204.17 | $204.17 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $204.17 / $269.15
| Professional | | $173.78 | $204.17 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $346.74 / $562.34
| Professional | | $275.42 | $346.74 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $478.63 / $645.65
| Professional | | $389.05 | $478.63 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $17.78 / $141.25 / $239.88
| Facility | | $17.78 | $141.25 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $181.97 / $295.12
| Professional | | $112.20 | $181.97 | $295.12 |