- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $407.38
| Facility | | $173.78 | $173.78 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $173.78 / $173.78
| Professional | | $162.18 | $173.78 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $245.47 / $512.86
| Facility | | $138.04 | $245.47 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $190.55
| Professional | | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $346.74 / $354.81
| Facility | | $181.97 | $346.74 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $181.97
| Professional | | $181.97 | $181.97 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $457.09 / $724.44
| Facility | | $151.36 | $457.09 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $309.03
| Professional | | $190.55 | $190.55 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $186.21
| Professional | | $169.82 | $169.82 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $223.87 / $323.59
| Facility | | $190.55 | $223.87 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $190.55 / $537.03
| Facility | | $147.91 | $190.55 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $190.55
| Professional | | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $204.17 / $512.86
| Facility | | $165.96 | $204.17 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $199.53
| Professional | | $190.55 | $190.55 | $199.53 |
- 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
- $162.18 / $204.17 / $204.17
| Professional | | $162.18 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $218.78 / $269.15
| Professional | | $169.82 | $218.78 | $269.15 |