- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $239.88 / $281.84
| Professional | | $123.03 | $239.88 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Facility | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Professional | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,778.28 / $1,778.28
| Professional | | $1,621.81 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $251.19 / $323.59
| Facility | | $162.18 | $251.19 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $245.47 / $281.84
| Professional | | $158.49 | $245.47 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $323.59 / $467.74
| Professional | | $177.83 | $323.59 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $251.19 / $323.59
| Facility | | $162.18 | $251.19 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Professional | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $263.03
| Facility | | $81.28 | $81.28 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $147.91 / $169.82
| Professional | | $100.00 | $147.91 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Professional | | $323.59 | $323.59 | $323.59 |