- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $190.55
| Facility | | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $190.55 / $316.23
| Professional | | $151.36 | $190.55 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $630.96
| Facility | | $380.19 | $380.19 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $354.81 / $426.58
| Professional | | $354.81 | $354.81 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $1,174.90 / $1,862.09
| Facility | | $302.00 | $1,174.90 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $549.54 / $724.44
| Professional | | $257.04 | $549.54 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $316.23 / $478.63
| Facility | | $190.55 | $316.23 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $371.54 / $457.09
| Professional | | $213.80 | $371.54 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $371.54 / $1,621.81
| Facility | | $190.55 | $371.54 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $245.47 / $426.58
| Professional | | $173.78 | $245.47 | $426.58 |
- 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
- $269.15 / $436.52 / $758.58
| Professional | | $269.15 | $436.52 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $575.44 / $1,071.52
| Professional | | $380.19 | $575.44 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $758.58 / $1,995.26
| Facility | | $302.00 | $758.58 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $501.19 / $1,995.26
| Professional | | $257.04 | $501.19 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $257.04 / $281.84
| Facility | | $204.17 | $257.04 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $199.53 / $309.03
| Professional | | $151.36 | $199.53 | $309.03 |