- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $380.19 / $1,174.90
| Facility | | $204.17 | $380.19 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $190.55 / $398.11
| Professional | | $120.23 | $190.55 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $302.00 / $407.38
| Facility | | $204.17 | $302.00 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $204.17 / $263.03
| Professional | | $173.78 | $204.17 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $446.68 / $524.81
| Facility | | $208.93 | $446.68 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $213.80 / $275.42
| Professional | | $102.33 | $213.80 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $257.04 / $691.83
| Facility | | $204.17 | $257.04 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $257.04 / $575.44
| Professional | | $204.17 | $257.04 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $177.83 / $213.80
| Professional | | $75.86 | $177.83 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $407.38
| Facility | | $204.17 | $204.17 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $245.47
| Professional | | $204.17 | $204.17 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $354.81 / $630.96
| Facility | | $204.17 | $354.81 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $245.47
| Professional | | $181.97 | $181.97 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $302.00 / $537.03
| Facility | | $234.42 | $302.00 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $204.17 / $263.03
| Professional | | $173.78 | $204.17 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $245.47 / $245.47
| Facility | | $204.17 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $85.11 / $229.09
| Professional | | $79.43 | $85.11 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $204.17 / $363.08
| Professional | | $91.20 | $204.17 | $363.08 |