- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $104.71 / $151.36
| Professional | | $89.13 | $104.71 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $354.81
| Facility | | $213.80 | $213.80 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $199.53 / $239.88
| Professional | | $190.55 | $199.53 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $489.78 / $1,047.13
| Facility | | $147.91 | $489.78 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $302.00 / $407.38
| Professional | | $107.15 | $302.00 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $173.78 / $263.03
| Facility | | $104.71 | $173.78 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $251.19 / $309.03
| Professional | | $190.55 | $251.19 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $208.93 / $977.24
| Facility | | $104.71 | $208.93 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $109.65 / $234.42
| Professional | | $93.33 | $109.65 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $134.90
| Professional | | $54.95 | $70.79 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $338.84
| Facility | | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $239.88 / $416.87
| Professional | | $151.36 | $239.88 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $316.23 / $588.84
| Professional | | $213.80 | $316.23 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $426.58 / $977.24
| Facility | | $147.91 | $426.58 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $213.80 / $1,047.13
| Professional | | $107.15 | $213.80 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $109.65 / $213.80
| Facility | | $72.44 | $109.65 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $104.71 / $177.83
| Professional | | $74.13 | $104.71 | $177.83 |