- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $83.18
| Facility | | $83.18 | $83.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $83.18 / $120.23
| Professional | | $58.88 | $83.18 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $281.84
| Facility | | $169.82 | $169.82 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $190.55
| Professional | | $158.49 | $158.49 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $389.05 / $831.76
| Facility | | $112.20 | $389.05 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $239.88 / $323.59
| Professional | | $81.28 | $239.88 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $138.04 / $208.93
| Facility | | $83.18 | $138.04 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $151.36 / $204.17
| Professional | | $95.50 | $151.36 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $165.96 / $707.95
| Facility | | $83.18 | $165.96 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $83.18 / $181.97
| Professional | | $67.61 | $83.18 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $67.61 / $85.11
| Professional | | $50.12 | $67.61 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $269.15
| Facility | | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $190.55 / $331.13
| Professional | | $120.23 | $190.55 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $257.04 / $426.58
| Professional | | $169.82 | $257.04 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $338.84 / $707.95
| Facility | | $112.20 | $338.84 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $162.18 / $891.25
| Professional | | $81.28 | $162.18 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $75.86 / $169.82
| Facility | | $45.71 | $75.86 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $83.18 / $138.04
| Professional | | $54.95 | $83.18 | $138.04 |