- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $104.71
| Facility | | $95.50 | $95.50 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $107.15 / $194.98
| Professional | | $91.20 | $107.15 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,162.28 / $3,388.44 / $4,168.69
| Facility | | $3,162.28 | $3,388.44 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $158.49
| Professional | | $104.71 | $104.71 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $223.87 / $223.87
| Facility | | $79.43 | $223.87 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Facility | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $169.82
| Professional | | $123.03 | $123.03 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $2,041.74 / $2,041.74
| Professional | | $1,318.26 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $177.83 / $295.12
| Facility | | $95.50 | $177.83 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $117.49 / $223.87
| Professional | | $91.20 | $117.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Professional | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $169.82 / $295.12
| Facility | | $97.72 | $169.82 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $169.82
| Professional | | $123.03 | $123.03 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $158.49 / $234.42
| Facility | | $91.20 | $158.49 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $125.89 / $154.88
| Professional | | $85.11 | $125.89 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $223.87 / $223.87
| Professional | | $123.03 | $223.87 | $223.87 |