- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $416.87
| Facility | | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $416.87 / $416.87
| Professional | | $309.03 | $416.87 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $1,174.90 / $1,174.90
| Facility | | $645.65 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $645.65 / $870.96
| Professional | | $512.86 | $645.65 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $354.81 / $3,162.28
| Facility | | $354.81 | $354.81 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $794.33 / $1,230.27
| Professional | | $354.81 | $794.33 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $416.87 / $758.58
| Facility | | $169.82 | $416.87 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $354.81 / $354.81
| Professional | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $724.44 / $2,951.21
| Facility | | $169.82 | $724.44 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $309.03 / $588.84
| Professional | | $251.19 | $309.03 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $64.57 / $389.05
| Professional | | $50.12 | $64.57 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $588.84 / $1,096.48
| Professional | | $309.03 | $588.84 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $123.03 / $165.96
| Professional | | $85.11 | $123.03 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $1,258.93 / $2,951.21
| Facility | | $354.81 | $1,258.93 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $354.81 / $446.68
| Professional | | $302.00 | $354.81 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $24.55 / $190.55 / $416.87
| Facility | | $24.55 | $190.55 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $309.03 / $645.65
| Professional | | $218.78 | $309.03 | $645.65 |