- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $181.97 / $223.87
| Facility | | $104.71 | $181.97 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $251.19 / $380.19
| Professional | | $177.83 | $251.19 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $316.23 / $323.59
| Professional | | $275.42 | $316.23 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $426.58
| Facility | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $398.11 / $426.58
| Professional | | $316.23 | $398.11 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $316.23 / $758.58
| Facility | | $316.23 | $316.23 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $316.23
| Professional | | $229.09 | $229.09 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $208.93
| Facility | | $144.54 | $144.54 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $257.04 / $426.58
| Professional | | $186.21 | $257.04 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $194.98 / $239.88
| Professional | | $125.89 | $194.98 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $218.78 / $562.34
| Facility | | $162.18 | $218.78 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $208.93 / $302.00
| Professional | | $173.78 | $208.93 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $426.58
| Professional | | $194.98 | $194.98 | $426.58 |