- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Facility | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $125.89 / $169.82
| Professional | | $85.11 | $125.89 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $338.84 / $338.84
| Facility | | $186.21 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $186.21 / $251.19
| Professional | | $173.78 | $186.21 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $144.54 / $724.44
| Facility | | $114.82 | $144.54 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $218.78 / $363.08
| Professional | | $114.82 | $218.78 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $177.83 / $257.04
| Facility | | $107.15 | $177.83 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $229.09 / $812.83
| Facility | | $107.15 | $229.09 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $123.03 / $204.17
| Professional | | $89.13 | $123.03 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.02 / $54.95 / $134.90
| Professional | | $12.02 | $54.95 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $177.83 / $323.59
| Professional | | $109.65 | $177.83 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $24.55 / $38.90 / $51.29
| Professional | | $24.55 | $38.90 | $51.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $371.54 / $812.83
| Facility | | $114.82 | $371.54 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $114.82 / $138.04
| Professional | | $97.72 | $114.82 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10.23 / $75.86 / $141.25
| Facility | | $10.23 | $75.86 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $120.23 / $204.17
| Professional | | $74.13 | $120.23 | $204.17 |