- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $131.83 / $263.03
| Facility | | $89.13 | $131.83 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $104.71
| Professional | | $87.10 | $87.10 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $194.98
| Facility | | $109.65 | $109.65 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $109.65
| Professional | | $87.10 | $87.10 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $173.78 / $416.87
| Facility | | $144.54 | $173.78 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $112.20 / $162.18
| Professional | | $87.10 | $112.20 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $93.33
| Facility | | $85.11 | $85.11 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $169.82 / $169.82
| Professional | | $125.89 | $169.82 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $93.33
| Facility | | $85.11 | $85.11 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $93.33 / $512.86
| Professional | | $85.11 | $93.33 | $512.86 |
- 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
- $109.65 / $114.82 / $123.03
| Facility | | $109.65 | $114.82 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $123.03 / $213.80
| Professional | | $93.33 | $123.03 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $151.36 / $275.42
| Professional | | $87.10 | $151.36 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $87.10 / $512.86
| Facility | | $81.28 | $87.10 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $177.83 / $512.86
| Professional | | $87.10 | $177.83 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $144.54
| Professional | | $117.49 | $117.49 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $275.42
| Facility | | $117.49 | $117.49 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $97.72 / $123.03
| Professional | | $87.10 | $97.72 | $123.03 |