- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $257.04 / $794.33
| Facility | | $128.82 | $257.04 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $128.82 / $269.15
| Professional | | $81.28 | $128.82 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $204.17 / $275.42
| Facility | | $138.04 | $204.17 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $138.04 / $177.83
| Professional | | $117.49 | $138.04 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $281.84 / $354.81
| Facility | | $138.04 | $281.84 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $144.54 / $186.21
| Professional | | $66.07 | $144.54 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $169.82 / $616.60
| Facility | | $138.04 | $169.82 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $169.82 / $416.87
| Professional | | $138.04 | $169.82 | $416.87 |
- 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
- $138.04 / $138.04 / $275.42
| Facility | | $138.04 | $138.04 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $165.96 / $190.55
| Professional | | $138.04 | $165.96 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $218.78 / $426.58
| Facility | | $138.04 | $218.78 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $165.96
| Professional | | $123.03 | $123.03 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $204.17 / $363.08
| Facility | | $158.49 | $204.17 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $138.04 / $177.83
| Professional | | $117.49 | $138.04 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $165.96 / $165.96
| Facility | | $138.04 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $154.88
| Professional | | $57.54 | $57.54 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $138.04 / $245.47
| Professional | | $61.66 | $138.04 | $245.47 |