- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $77.62
| Facility | | $77.62 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $131.83
| Professional | | $70.79 | $70.79 | $131.83 |
- 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
- $125.89 / $125.89 / $141.25
| Professional | | $125.89 | $125.89 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $169.82 / $562.34
| Facility | | $147.91 | $169.82 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $346.74 / $588.84
| Facility | | $239.88 | $346.74 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $275.42 / $346.74
| Professional | | $190.55 | $275.42 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $50.12 / $75.86
| Professional | | $30.20 | $50.12 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $89.13
| Facility | | $70.79 | $70.79 | $89.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $251.19 / $251.19
| Facility | | $107.15 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $107.15 / $107.15
| Professional | | $87.10 | $107.15 | $107.15 |
- 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
- $123.03 / $125.89 / $141.25
| Professional | | $123.03 | $125.89 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $102.33 / $102.33
| Facility | | $74.13 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $125.89 / $125.89
| Professional | | $74.13 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $154.88 / $295.12
| Professional | | $134.90 | $154.88 | $295.12 |