- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $281.84 / $457.09
| Facility | | $87.10 | $281.84 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $89.13 / $131.83
| Professional | | $64.57 | $89.13 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $158.49 / $177.83
| Professional | | $131.83 | $158.49 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $173.78 / $173.78
| Facility | | $151.36 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $199.53
| Professional | | $151.36 | $151.36 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Facility | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $102.33
| Professional | | $74.13 | $74.13 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $208.93 / $501.19
| Facility | | $89.13 | $208.93 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $199.53 / $331.13
| Professional | | $89.13 | $199.53 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $134.90 / $147.91
| Professional | | $75.86 | $134.90 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $173.78 / $177.83
| Facility | | $141.25 | $173.78 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $165.96 / $177.83
| Professional | | $151.36 | $165.96 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $257.04 / $354.81
| Facility | | $154.88 | $257.04 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $173.78
| Professional | | $147.91 | $147.91 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Facility | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $199.53
| Professional | | $151.36 | $151.36 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $229.09 / $229.09
| Facility | | $69.18 | $229.09 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $75.86 / $134.90
| Professional | | $66.07 | $75.86 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $151.36 / $269.15
| Professional | | $77.62 | $151.36 | $269.15 |