- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $812.83 / $891.25
| Facility | | $107.15 | $812.83 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $204.17 / $316.23
| Professional | | $158.49 | $204.17 | $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
- $389.05 / $389.05 / $467.74
| Professional | | $389.05 | $389.05 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $1,288.25 / $2,041.74
| Facility | | $275.42 | $1,288.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $588.84 / $794.33
| Professional | | $234.42 | $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
- $234.42 / $371.54 / $501.19
| Professional | | $234.42 | $371.54 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $407.38 / $1,548.82
| Facility | | $204.17 | $407.38 | $1,548.82 |
- 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 / $64.57 / $85.11
| Professional | | $54.95 | $64.57 | $85.11 |
- 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
- $275.42 / $831.76 / $1,698.24
| Facility | | $275.42 | $831.76 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $467.74 / $1,949.84
| Professional | | $234.42 | $467.74 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $234.42 / $251.19
| Facility | | $177.83 | $234.42 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $204.17 / $338.84
| Professional | | $134.90 | $204.17 | $338.84 |