- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $199.53
| Facility | | $83.18 | $83.18 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $57.54 / $107.15
| Professional | | $41.69 | $57.54 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $125.89 / $125.89
| Facility | | $112.20 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $144.54
| Professional | | $112.20 | $112.20 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $60.26
| Facility | | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $43.65 / $60.26
| Professional | | $43.65 | $43.65 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $144.54 / $363.08
| Facility | | $60.26 | $144.54 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $138.04 / $223.87
| Professional | | $60.26 | $138.04 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $97.72 / $107.15
| Professional | | $75.86 | $97.72 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $125.89 / $128.82
| Facility | | $102.33 | $125.89 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $154.88
| Professional | | $128.82 | $128.82 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $186.21 / $257.04
| Facility | | $112.20 | $186.21 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $125.89
| Professional | | $107.15 | $107.15 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Facility | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $144.54
| Professional | | $112.20 | $112.20 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $131.83 / $158.49
| Facility | | $63.10 | $131.83 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $64.57 / $91.20
| Professional | | $45.71 | $64.57 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $112.20 / $194.98
| Professional | | $52.48 | $112.20 | $194.98 |