- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $281.84 / $660.69
| Facility | | $91.20 | $281.84 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $275.42 / $870.96
| Professional | | $165.96 | $275.42 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $416.87 / $724.44
| Professional | | $239.88 | $416.87 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $407.38 / $407.38
| Facility | | $363.08 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $467.74
| Professional | | $363.08 | $363.08 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $288.40
| Facility | | $213.80 | $213.80 | $288.40 |
- 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
- $338.84 / $537.03 / $1,258.93
| Facility | | $338.84 | $537.03 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $501.19 / $794.33
| Professional | | $338.84 | $501.19 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $316.23 / $346.74
| Professional | | $288.40 | $316.23 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $407.38 / $416.87
| Facility | | $331.13 | $407.38 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $630.96 / $831.76
| Facility | | $363.08 | $630.96 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $407.38
| Professional | | $346.74 | $346.74 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $407.38 / $407.38
| Facility | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $467.74
| Professional | | $363.08 | $363.08 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $512.86 / $512.86
| Facility | | $154.88 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $181.97 / $302.00
| Professional | | $147.91 | $181.97 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $363.08 / $630.96
| Professional | | $199.53 | $363.08 | $630.96 |