- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $234.42 / $602.56
| Facility | | $81.28 | $234.42 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $275.42 / $501.19
| Professional | | $194.98 | $275.42 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $354.81 / $707.95
| Professional | | $275.42 | $354.81 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $478.63 / $478.63
| Facility | | $478.63 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $446.68 / $478.63
| Professional | | $346.74 | $446.68 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $776.25
| Facility | | $295.12 | $295.12 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $295.12
| Professional | | $213.80 | $213.80 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $251.19 / $354.81
| Facility | | $173.78 | $251.19 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $281.84 / $478.63
| Professional | | $204.17 | $281.84 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $257.04 / $323.59
| Professional | | $169.82 | $257.04 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $234.42 / $588.84
| Facility | | $165.96 | $234.42 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $229.09 / $309.03
| Professional | | $181.97 | $229.09 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $478.63
| Professional | | $257.04 | $257.04 | $478.63 |