- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $158.49 / $204.17
| Facility | | $64.57 | $158.49 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $186.21 / $407.38
| Professional | | $141.25 | $186.21 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $251.19 / $346.74
| Professional | | $213.80 | $251.19 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $338.84
| Facility | | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $316.23 / $338.84
| Professional | | $251.19 | $316.23 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $549.54
| Facility | | $194.98 | $194.98 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $194.98
| Professional | | $141.25 | $141.25 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $162.18
| Facility | | $114.82 | $114.82 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $204.17 / $338.84
| Professional | | $74.13 | $204.17 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $199.53 / $245.47
| Professional | | $128.82 | $199.53 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $154.88 / $426.58
| Facility | | $120.23 | $154.88 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $162.18 / $223.87
| Professional | | $131.83 | $162.18 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $338.84
| Professional | | $199.53 | $199.53 | $338.84 |