- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $309.03 / $954.99
| Facility | | $61.66 | $309.03 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $173.78 / $263.03
| Professional | | $134.90 | $173.78 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $338.84
| Professional | | $257.04 | $257.04 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $363.08 / $724.44
| Facility | | $338.84 | $363.08 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $204.17 / $446.68
| Professional | | $162.18 | $204.17 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $288.40
| Professional | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $263.03 / $371.54
| Facility | | $154.88 | $263.03 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $275.42 / $416.87
| Professional | | $199.53 | $275.42 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $245.47
| Facility | | $218.78 | $218.78 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $239.88
| Professional | | $158.49 | $158.49 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $489.78
| Facility | | $218.78 | $218.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $218.78
| Professional | | $158.49 | $158.49 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $204.17 / $295.12
| Professional | | $144.54 | $204.17 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $407.38 / $407.38
| Facility | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $380.19 / $691.83
| Professional | | $338.84 | $380.19 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $257.04 / $354.81
| Facility | | $123.03 | $257.04 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $158.49 / $234.42
| Professional | | $112.20 | $158.49 | $234.42 |