- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $165.96 / $616.60
| Facility | | $95.50 | $165.96 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $169.82 / $295.12
| Professional | | $102.33 | $169.82 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $239.88 / $363.08
| Professional | | $204.17 | $239.88 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $338.84 / $676.08
| Facility | | $316.23 | $338.84 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $199.53 / $426.58
| Professional | | $147.91 | $199.53 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $316.23 / $316.23
| Professional | | $263.03 | $316.23 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $398.11 / $549.54
| Facility | | $309.03 | $398.11 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $446.68 / $812.83
| Professional | | $331.13 | $446.68 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $257.04
| Facility | | $213.80 | $213.80 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $213.80
| Professional | | $154.88 | $154.88 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $213.80 / $269.15
| Facility | | $97.72 | $213.80 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $181.97 / $398.11
| Professional | | $154.88 | $181.97 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $165.96 / $239.88
| Professional | | $120.23 | $165.96 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $380.19
| Facility | | $380.19 | $380.19 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $389.05 / $630.96
| Professional | | $269.15 | $389.05 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $257.04 / $426.58
| Facility | | $123.03 | $257.04 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $154.88 / $251.19
| Professional | | $104.71 | $154.88 | $251.19 |