- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $346.74
| Facility | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $186.21 / $346.74
| Professional | | $128.82 | $186.21 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $309.03 / $776.25
| Facility | | $245.47 | $309.03 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $346.74 / $346.74
| Professional | | $323.59 | $346.74 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $776.25 / $1,348.96
| Facility | | $97.72 | $776.25 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $758.58 / $1,174.90
| Professional | | $467.74 | $758.58 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $407.38 / $407.38
| Facility | | $295.12 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $407.38
| Professional | | $346.74 | $346.74 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $575.44 / $933.25
| Professional | | $389.05 | $575.44 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $2,238.72 / $2,238.72
| Professional | | $1,949.84 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $70.79
| Professional | | $54.95 | $54.95 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $380.19 / $575.44
| Facility | | $186.21 | $380.19 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $407.38
| Professional | | $346.74 | $346.74 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $229.09 / $407.38
| Facility | | $28.84 | $229.09 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $269.15 / $501.19
| Professional | | $158.49 | $269.15 | $501.19 |