- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $323.59
| Facility | | $138.04 | $138.04 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $107.15 / $177.83
| Professional | | $87.10 | $107.15 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $199.53 / $199.53
| Facility | | $177.83 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $229.09
| Professional | | $177.83 | $177.83 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $112.20
| Professional | | $81.28 | $81.28 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $251.19 / $575.44
| Facility | | $112.20 | $251.19 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $239.88 / $416.87
| Professional | | $112.20 | $239.88 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $154.88 / $169.82
| Professional | | $75.86 | $154.88 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $199.53 / $204.17
| Facility | | $162.18 | $199.53 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $177.83 / $204.17
| Professional | | $162.18 | $177.83 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $295.12 / $407.38
| Facility | | $177.83 | $295.12 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $199.53
| Professional | | $169.82 | $169.82 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $229.09
| Professional | | $177.83 | $177.83 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $245.47 / $295.12
| Facility | | $89.13 | $245.47 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $102.33 / $169.82
| Professional | | $83.18 | $102.33 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $177.83 / $309.03
| Professional | | $77.62 | $177.83 | $309.03 |