- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $165.96 / $165.96
| Facility | | $147.91 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $169.82 / $208.93
| Professional | | $131.83 | $169.82 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $245.47 / $407.38
| Professional | | $245.47 | $245.47 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $120.23 / $125.89
| Facility | | $114.82 | $120.23 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $186.21 / $208.93
| Professional | | $144.54 | $186.21 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $575.44
| Facility | | $295.12 | $295.12 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $186.21 / $239.88
| Professional | | $91.20 | $186.21 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $36.31
| Professional | | $32.36 | $33.11 | $36.31 |
- 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
- $147.91 / $204.17 / $354.81
| Professional | | $147.91 | $204.17 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $194.98
| Professional | | $154.88 | $154.88 | $194.98 |