- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $112.20 / $831.76
| Professional | | $87.10 | $112.20 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $190.55 / $190.55
| Facility | | $169.82 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $199.53 / $218.78
| Professional | | $26.30 | $199.53 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Facility | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $162.18
| Professional | | $104.71 | $104.71 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $323.59
| Facility | | $199.53 | $199.53 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $323.59
| Professional | | $199.53 | $199.53 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $218.78 / $269.15
| Professional | | $75.86 | $218.78 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.50 / $144.54 / $208.93
| Facility | | $19.50 | $144.54 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $17.78 / $144.54 / $223.87
| Professional | | $17.78 | $144.54 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $158.49 / $223.87
| Facility | | $15.85 | $158.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $26.30 / $194.98
| Professional | | $15.85 | $26.30 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $190.55
| Facility | | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $199.53 / $263.03
| Professional | | $26.30 | $199.53 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9.55 / $95.50 / $154.88
| Facility | | $9.55 | $95.50 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $144.54 / $181.97
| Professional | | $95.50 | $144.54 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Professional | | $213.80 | $213.80 | $213.80 |