- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $154.88 / $478.63
| Facility | | $114.82 | $154.88 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $165.96 / $281.84
| Professional | | $131.83 | $165.96 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $331.13 / $478.63
| Professional | | $245.47 | $331.13 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Facility | | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $302.00 / $323.59
| Professional | | $239.88 | $302.00 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $501.19
| Facility | | $177.83 | $177.83 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $177.83
| Professional | | $128.82 | $128.82 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $169.82 / $245.47
| Facility | | $120.23 | $169.82 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $194.98 / $323.59
| Professional | | $141.25 | $194.98 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $257.04
| Professional | | $257.04 | $257.04 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $147.91 / $389.05
| Facility | | $109.65 | $147.91 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $154.88 / $204.17
| Professional | | $123.03 | $154.88 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $323.59
| Professional | | $169.82 | $169.82 | $323.59 |