- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $398.11
| Facility | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $398.11 / $398.11
| Professional | | $204.17 | $398.11 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $1,122.02 / $1,122.02
| Facility | | $616.60 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $602.56 / $851.14
| Professional | | $354.81 | $602.56 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $2,344.23
| Facility | | $295.12 | $295.12 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $707.95 / $1,174.90
| Professional | | $295.12 | $707.95 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $398.11 / $707.95
| Facility | | $162.18 | $398.11 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $338.84
| Professional | | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $676.08 / $2,630.27
| Facility | | $162.18 | $676.08 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $295.12 / $549.54
| Professional | | $239.88 | $295.12 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $58.88 / $89.13
| Professional | | $50.12 | $58.88 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $562.34 / $1,047.13
| Professional | | $288.40 | $562.34 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $117.49 / $162.18
| Professional | | $81.28 | $117.49 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $1,202.26 / $2,691.53
| Facility | | $295.12 | $1,202.26 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $295.12 / $416.87
| Professional | | $251.19 | $295.12 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $177.83 / $398.11
| Facility | | $23.99 | $177.83 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $295.12 / $575.44
| Professional | | $194.98 | $295.12 | $575.44 |