- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $724.44 / $933.25
| Facility | | $181.97 | $724.44 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $208.93 / $331.13
| Professional | | $169.82 | $208.93 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $407.38
| Professional | | $295.12 | $295.12 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $407.38 / $407.38
| Facility | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $363.08 / $407.38
| Professional | | $295.12 | $363.08 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $295.12 / $478.63
| Facility | | $263.03 | $295.12 | $478.63 |
- 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
- $169.82 / $169.82 / $245.47
| Facility | | $169.82 | $169.82 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $239.88 / $407.38
| Professional | | $173.78 | $239.88 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $158.49 / $181.97
| Professional | | $102.33 | $158.49 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $281.84 / $512.86
| Facility | | $169.82 | $281.84 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $199.53 / $288.40
| Professional | | $169.82 | $199.53 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $407.38
| Professional | | $158.49 | $158.49 | $407.38 |