- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Facility | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $177.83 / $245.47
| Professional | | $123.03 | $177.83 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $478.63 / $478.63
| Facility | | $263.03 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $263.03 / $354.81
| Professional | | $223.87 | $263.03 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $213.80 / $1,047.13
| Facility | | $165.96 | $213.80 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $316.23 / $501.19
| Professional | | $165.96 | $316.23 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $245.47 / $371.54
| Facility | | $158.49 | $245.47 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Professional | | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $323.59 / $1,202.26
| Facility | | $158.49 | $323.59 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $177.83 / $302.00
| Professional | | $128.82 | $177.83 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $64.57 / $208.93
| Professional | | $50.12 | $64.57 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $251.19 / $446.68
| Professional | | $158.49 | $251.19 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $56.23 / $75.86
| Professional | | $34.67 | $56.23 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $512.86 / $1,202.26
| Facility | | $165.96 | $512.86 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $165.96 / $194.98
| Professional | | $141.25 | $165.96 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $14.79 / $112.20 / $194.98
| Facility | | $14.79 | $112.20 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $173.78 / $302.00
| Professional | | $107.15 | $173.78 | $302.00 |