- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $131.83 / $380.19
| Facility | | $57.54 | $131.83 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $147.91 / $263.03
| Professional | | $114.82 | $147.91 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $208.93 / $426.58
| Professional | | $177.83 | $208.93 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $281.84 / $281.84
| Facility | | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $263.03 / $281.84
| Professional | | $208.93 | $263.03 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $436.52
| Facility | | $134.90 | $134.90 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $134.90
| Professional | | $97.72 | $97.72 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $204.17 / $213.80
| Facility | | $190.55 | $204.17 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $169.82 / $281.84
| Professional | | $61.66 | $169.82 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $223.87
| Professional | | $218.78 | $218.78 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $123.03 / $331.13
| Facility | | $93.33 | $123.03 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $134.90 / $173.78
| Professional | | $107.15 | $134.90 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $281.84
| Professional | | $147.91 | $147.91 | $281.84 |