- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $204.17 / $281.84
| Professional | | $141.25 | $204.17 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $691.83
| Facility | | $416.87 | $416.87 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $389.05 / $457.09
| Professional | | $354.81 | $389.05 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $954.99 / $2,041.74
| Facility | | $269.15 | $954.99 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $588.84 / $794.33
| Professional | | $194.98 | $588.84 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $338.84 / $512.86
| Facility | | $194.98 | $338.84 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $457.09 / $562.34
| Professional | | $371.54 | $457.09 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $407.38 / $1,698.24
| Facility | | $204.17 | $407.38 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $204.17 / $446.68
| Professional | | $162.18 | $204.17 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $302.00
| Professional | | $54.95 | $70.79 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $660.69
| Facility | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $467.74 / $812.83
| Professional | | $295.12 | $467.74 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $630.96 / $1,023.29
| Professional | | $416.87 | $630.96 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $831.76 / $2,041.74
| Facility | | $269.15 | $831.76 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $354.81 / $2,511.89
| Professional | | $194.98 | $354.81 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $186.21 / $416.87
| Facility | | $123.03 | $186.21 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $204.17 / $346.74
| Professional | | $134.90 | $204.17 | $346.74 |