- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $446.68 / $2,041.74
| Facility | | $338.84 | $446.68 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $257.04 / $1,513.56
| Professional | | $204.17 | $257.04 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $239.88 / $489.78
| Facility | | $213.80 | $239.88 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $446.68
| Professional | | $204.17 | $204.17 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $223.87 / $371.54
| Facility | | $87.10 | $223.87 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $223.87 / $467.74
| Professional | | $208.93 | $223.87 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $309.03 / $467.74
| Facility | | $204.17 | $309.03 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $234.42
| Professional | | $204.17 | $204.17 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $204.17 / $245.47
| Professional | | $162.18 | $204.17 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $208.93 / $398.11
| Professional | | $181.97 | $208.93 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,023.29 / $1,023.29
| Facility | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $213.80 / $407.38
| Facility | | $204.17 | $213.80 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $239.88
| Professional | | $204.17 | $204.17 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $354.81 / $354.81
| Professional | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $223.87 / $346.74
| Professional | | $162.18 | $223.87 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.21 / $204.17 / $676.08
| Facility | | $0.21 | $204.17 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $204.17 / $389.05
| Professional | | $81.28 | $204.17 | $389.05 |