- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $239.88
| Facility | | $102.33 | $102.33 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $89.13 / $177.83
| Professional | | $67.61 | $89.13 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $147.91 / $147.91
| Facility | | $131.83 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $169.82
| Professional | | $131.83 | $131.83 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $131.83
| Professional | | $97.72 | $97.72 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $213.80 / $436.52
| Facility | | $95.50 | $213.80 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $194.98 / $346.74
| Professional | | $95.50 | $194.98 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $117.49 / $194.98
| Professional | | $104.71 | $117.49 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $147.91 / $151.36
| Facility | | $120.23 | $147.91 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $151.36 / $173.78
| Professional | | $120.23 | $151.36 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $223.87 / $302.00
| Facility | | $131.83 | $223.87 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $147.91
| Professional | | $125.89 | $125.89 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Facility | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $169.82
| Professional | | $131.83 | $131.83 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $204.17 / $245.47
| Facility | | $74.13 | $204.17 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $81.28 / $144.54
| Professional | | $70.79 | $81.28 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $131.83 / $234.42
| Professional | | $64.57 | $131.83 | $234.42 |