- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $204.17
| Facility | | $85.11 | $85.11 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $77.62 / $114.82
| Professional | | $56.23 | $77.62 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $125.89 / $125.89
| Facility | | $112.20 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $144.54
| Professional | | $112.20 | $112.20 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $81.28
| Facility | | $81.28 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $81.28
| Professional | | $58.88 | $58.88 | $81.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $190.55 / $371.54
| Facility | | $89.13 | $190.55 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $165.96 / $295.12
| Professional | | $89.13 | $165.96 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $97.72 / $109.65
| Professional | | $75.86 | $97.72 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $125.89 / $134.90
| Facility | | $102.33 | $125.89 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $128.82 / $169.82
| Professional | | $114.82 | $128.82 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $190.55 / $257.04
| Facility | | $112.20 | $190.55 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $125.89
| Professional | | $107.15 | $107.15 | $125.89 |
- 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
- $112.20 / $112.20 / $144.54
| Professional | | $112.20 | $112.20 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $173.78 / $208.93
| Facility | | $63.10 | $173.78 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $69.18 / $123.03
| Professional | | $60.26 | $69.18 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $112.20 / $194.98
| Professional | | $54.95 | $112.20 | $194.98 |