- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $275.42 / $870.96
| Facility | | $173.78 | $275.42 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $114.82 / $239.88
| Professional | | $81.28 | $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 / $158.49
| Professional | | $104.71 | $123.03 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $257.04 / $389.05
| Facility | | $109.65 | $257.04 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $128.82 / $186.21
| Professional | | $69.18 | $128.82 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $177.83 / $426.58
| Facility | | $123.03 | $177.83 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $173.78 / $371.54
| Professional | | $123.03 | $173.78 | $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 / $123.03
| Professional | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $213.80 / $380.19
| Facility | | $123.03 | $213.80 | $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 / $158.49
| Professional | | $104.71 | $123.03 | $158.49 |
- 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 / $70.79 / $147.91
| Professional | | $51.29 | $70.79 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $123.03 / $218.78
| Professional | | $54.95 | $123.03 | $218.78 |