- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $229.09 / $794.33
| Facility | | $123.03 | $229.09 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $114.82 / $239.88
| Professional | | $72.44 | $114.82 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $181.97 / $245.47
| Facility | | $128.82 | $181.97 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $123.03 / $162.18
| Professional | | $104.71 | $123.03 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $257.04 / $389.05
| Facility | | $83.18 | $257.04 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $128.82 / $165.96
| Professional | | $69.18 | $128.82 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $190.55 / $416.87
| Facility | | $123.03 | $190.55 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $181.97 / $371.54
| Professional | | $123.03 | $181.97 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $75.86
| Professional | | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $245.47
| Facility | | $123.03 | $123.03 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $134.90
| Professional | | $123.03 | $123.03 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $194.98 / $380.19
| Facility | | $123.03 | $194.98 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $147.91
| Professional | | $109.65 | $109.65 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $181.97 / $323.59
| Facility | | $141.25 | $181.97 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $123.03 / $162.18
| Professional | | $104.71 | $123.03 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $147.91 / $147.91
| Facility | | $123.03 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $63.10 / $147.91
| Professional | | $51.29 | $63.10 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $123.03 / $218.78
| Professional | | $54.95 | $123.03 | $218.78 |