- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $316.23
| Facility | | $134.90 | $134.90 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $114.82 / $173.78
| Professional | | $83.18 | $114.82 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $194.98 / $194.98
| Facility | | $173.78 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $223.87
| Professional | | $173.78 | $173.78 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Facility | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $123.03
| Professional | | $91.20 | $91.20 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $288.40 / $562.34
| Facility | | $120.23 | $288.40 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $251.19 / $446.68
| Professional | | $120.23 | $251.19 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $151.36 / $165.96
| Professional | | $75.86 | $151.36 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $194.98 / $204.17
| Facility | | $158.49 | $194.98 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Professional | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $288.40 / $398.11
| Facility | | $173.78 | $288.40 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $194.98
| Professional | | $165.96 | $165.96 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Facility | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $223.87
| Professional | | $173.78 | $173.78 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $263.03 / $316.23
| Facility | | $95.50 | $263.03 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $102.33 / $181.97
| Professional | | $89.13 | $102.33 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $173.78 / $302.00
| Professional | | $72.44 | $173.78 | $302.00 |