- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $223.87 / $457.09
| Facility | | $169.82 | $223.87 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $173.78 / $288.40
| Professional | | $169.82 | $173.78 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $181.97
| Facility | | $173.78 | $173.78 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Professional | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $131.83
| Facility | | $125.89 | $125.89 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $229.09 / $251.19
| Facility | | $128.82 | $229.09 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $707.95
| Professional | | $173.78 | $173.78 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $204.17 / $588.84
| Facility | | $165.96 | $204.17 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $208.93
| Professional | | $169.82 | $169.82 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $173.78
| Facility | | $165.96 | $165.96 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $173.78
| Professional | | $165.96 | $165.96 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $50,118.72 / $75,857.76
| Facility | | $208.93 | $50,118.72 | $75,857.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $173.78 / $269.15
| Facility | | $162.18 | $173.78 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $169.82 / $257.04
| Professional | | $144.54 | $169.82 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $194.98
| Facility | | $165.96 | $165.96 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $7.59 / $165.96 / $199.53
| Professional | | $7.59 | $165.96 | $199.53 |