- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $26.30 / $26.30
| Facility | | $23.99 | $26.30 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $186.21 / $1,258.93
| Professional | | $120.23 | $186.21 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $288.40 / $288.40
| Professional | | $257.04 | $288.40 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $331.13
| Facility | | $177.83 | $177.83 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $346.74 / $512.86
| Professional | | $177.83 | $346.74 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $323.59 / $1,380.38
| Facility | | $147.91 | $323.59 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $147.91 / $288.40
| Professional | | $97.72 | $147.91 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $794.33
| Professional | | $323.59 | $323.59 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $331.13
| Facility | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $741.31 / $794.33
| Professional | | $407.38 | $741.31 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $158.49 / $309.03
| Facility | | $102.33 | $158.49 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $147.91 / $229.09
| Professional | | $107.15 | $147.91 | $229.09 |