- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $316.23 / $524.81
| Facility | | $173.78 | $316.23 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $147.91 / $316.23
| Professional | | $104.71 | $147.91 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $457.09
| Facility | | $173.78 | $173.78 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $69.18 / $316.23
| Professional | | $69.18 | $69.18 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $173.78 / $173.78
| Facility | | $104.71 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $173.78 / $173.78
| Professional | | $128.82 | $173.78 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $371.54 / $630.96
| Facility | | $169.82 | $371.54 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $213.80 / $851.14
| Professional | | $107.15 | $213.80 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $288.40 / $676.08
| Facility | | $173.78 | $288.40 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $154.88 / $331.13
| Professional | | $123.03 | $154.88 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $165.96 / $204.17
| Professional | | $107.15 | $165.96 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $331.13 / $50,118.72
| Facility | | $229.09 | $331.13 | $50,118.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $181.97
| Professional | | $173.78 | $173.78 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $173.78 / $218.78
| Facility | | $158.49 | $173.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $123.03 / $269.15
| Professional | | $74.13 | $123.03 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $186.21
| Facility | | $107.15 | $107.15 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $165.96 / $346.74
| Professional | | $107.15 | $165.96 | $346.74 |