- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $213.80 / $10,471.29
| Facility | | $162.18 | $213.80 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $169.82 / $245.47
| Professional | | $162.18 | $169.82 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $323.59 / $549.54
| Facility | | $162.18 | $323.59 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $275.42
| Professional | | $162.18 | $162.18 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $263.03 / $398.11
| Professional | | $229.09 | $263.03 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $309.03 / $407.38
| Facility | | $229.09 | $309.03 | $407.38 |
- 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
- $138.04 / $162.18 / $239.88
| Professional | | $138.04 | $162.18 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $302.00
| Facility | | $162.18 | $162.18 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $204.17 / $239.88
| Facility | | $154.88 | $204.17 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $204.17 / $239.88
| Professional | | $154.88 | $204.17 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $199.53 / $354.81
| Facility | | $162.18 | $199.53 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $162.18 / $204.17
| Professional | | $158.49 | $162.18 | $204.17 |