- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $131.83 / $407.38
| Facility | | $53.70 | $131.83 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $223.87 / $1,047.13
| Professional | | $169.82 | $223.87 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $295.12
| Professional | | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $1,348.96
| Facility | | $380.19 | $380.19 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $218.78 / $354.81
| Professional | | $151.36 | $218.78 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $380.19
| Professional | | $229.09 | $229.09 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $245.47
| Facility | | $234.42 | $234.42 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $234.42
| Professional | | $169.82 | $169.82 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $309.03 / $1,905.46
| Facility | | $194.98 | $309.03 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $186.21 / $2,570.40
| Professional | | $125.89 | $186.21 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $309.03 / $309.03
| Facility | | $169.82 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $181.97 / $398.11
| Professional | | $141.25 | $181.97 | $398.11 |