- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Facility | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $128.82 / $204.17
| Professional | | $97.72 | $128.82 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $436.52
| Facility | | $263.03 | $263.03 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $245.47 / $288.40
| Professional | | $218.78 | $245.47 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $602.56 / $1,288.25
| Facility | | $173.78 | $602.56 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $371.54 / $501.19
| Professional | | $128.82 | $371.54 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $213.80 / $323.59
| Facility | | $128.82 | $213.80 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $309.03 / $380.19
| Professional | | $218.78 | $309.03 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $257.04 / $1,071.52
| Facility | | $131.83 | $257.04 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $147.91 / $295.12
| Professional | | $104.71 | $147.91 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $125.89
| Professional | | $54.95 | $70.79 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $416.87
| Facility | | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $295.12 / $512.86
| Professional | | $186.21 | $295.12 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $398.11 / $660.69
| Professional | | $263.03 | $398.11 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $524.81 / $1,071.52
| Facility | | $173.78 | $524.81 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $251.19 / $1,258.93
| Professional | | $128.82 | $251.19 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $158.49 / $263.03
| Facility | | $109.65 | $158.49 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $128.82 / $213.80
| Professional | | $89.13 | $128.82 | $213.80 |