- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $208.93
| Facility | | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $208.93 / $316.23
| Professional | | $138.04 | $208.93 | $316.23 |
- 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
- $346.74 / $389.05 / $457.09
| Professional | | $346.74 | $389.05 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $954.99 / $2,041.74
| Facility | | $263.03 | $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
- $204.17 / $338.84 / $512.86
| Facility | | $204.17 | $338.84 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $501.19 / $630.96
| Professional | | $371.54 | $501.19 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $407.38 / $1,659.59
| Facility | | $208.93 | $407.38 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $229.09 / $467.74
| Professional | | $154.88 | $229.09 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $173.78
| Professional | | $54.95 | $70.79 | $173.78 |
- 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 / $977.24
| Professional | | $416.87 | $630.96 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $831.76 / $1,737.80
| Facility | | $263.03 | $831.76 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $346.74 / $1,862.09
| Professional | | $194.98 | $346.74 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $229.09 / $416.87
| Facility | | $186.21 | $229.09 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $204.17 / $338.84
| Professional | | $138.04 | $204.17 | $338.84 |