- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $229.09 / $380.19
| Facility | | $177.83 | $229.09 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $208.93 / $676.08
| Professional | | $112.20 | $208.93 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $131.83 / $263.03
| Facility | | $114.82 | $131.83 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $114.82 / $457.09
| Professional | | $112.20 | $114.82 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $489.78 / $575.44
| Facility | | $87.10 | $489.78 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $144.54 / $389.05
| Professional | | $112.20 | $144.54 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $186.21 / $251.19
| Facility | | $112.20 | $186.21 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $112.20
| Professional | | $109.65 | $109.65 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $295.12
| Professional | | $97.72 | $123.03 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Professional | | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $177.83 / $275.42
| Facility | | $112.20 | $177.83 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $234.42
| Professional | | $109.65 | $109.65 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $229.09
| Professional | | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $120.23 / $186.21
| Professional | | $87.10 | $120.23 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $457.09 / $457.09
| Facility | | $109.65 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $302.00
| Professional | | $112.20 | $112.20 | $302.00 |