- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $257.04
| Facility | | $109.65 | $109.65 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $109.65 / $380.19
| Professional | | $74.13 | $109.65 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $134.90 / $165.96
| Professional | | $123.03 | $134.90 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $158.49 / $158.49
| Facility | | $141.25 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $181.97
| Professional | | $141.25 | $141.25 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $97.72 / $97.72
| Facility | | $95.50 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $97.72
| Professional | | $70.79 | $70.79 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $204.17 / $457.09
| Facility | | $91.20 | $204.17 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $190.55 / $338.84
| Professional | | $91.20 | $190.55 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $158.49 / $173.78
| Professional | | $75.86 | $158.49 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $158.49 / $162.18
| Facility | | $128.82 | $158.49 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $158.49 / $162.18
| Professional | | $128.82 | $158.49 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $239.88 / $323.59
| Facility | | $141.25 | $239.88 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $158.49
| Professional | | $134.90 | $134.90 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Facility | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $181.97
| Professional | | $141.25 | $141.25 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $199.53 / $239.88
| Facility | | $72.44 | $199.53 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $85.11 / $138.04
| Professional | | $67.61 | $85.11 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $141.25 / $251.19
| Professional | | $63.10 | $141.25 | $251.19 |