- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Facility | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $199.53 / $208.93
| Professional | | $194.98 | $199.53 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $134.90 / $295.12
| Professional | | $85.11 | $134.90 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $199.53 / $389.05
| Facility | | $169.82 | $199.53 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $147.91 / $181.97
| Professional | | $125.89 | $147.91 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $194.98 / $295.12
| Facility | | $165.96 | $194.98 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $229.09 / $346.74
| Facility | | $177.83 | $229.09 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $954.99
| Professional | | $218.78 | $218.78 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $64.57 / $85.11
| Professional | | $50.12 | $64.57 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Facility | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $204.17 / $416.87
| Professional | | $141.25 | $204.17 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $724.44
| Facility | | $204.17 | $204.17 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $1,096.48
| Professional | | $204.17 | $204.17 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $190.55 / $338.84
| Professional | | $147.91 | $190.55 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $190.55
| Facility | | $81.28 | $81.28 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $218.78
| Professional | | $125.89 | $125.89 | $218.78 |