- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $288.40 / $389.05
| Facility | | $213.80 | $288.40 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $338.84 / $436.52
| Professional | | $239.88 | $338.84 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $213.80 / $288.40
| Facility | | $204.17 | $213.80 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $380.19 / $436.52
| Professional | | $363.08 | $380.19 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $562.34 / $912.01
| Professional | | $457.09 | $562.34 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $501.19 / $758.58
| Facility | | $346.74 | $501.19 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $758.58 / $2,754.23
| Professional | | $398.11 | $758.58 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $645.65 / $1,096.48
| Professional | | $478.63 | $645.65 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $912.01 / $1,096.48
| Professional | | $575.44 | $912.01 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $977.24 / $977.24
| Professional | | $977.24 | $977.24 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.41 / $0.41 / $0.41
| Facility | | $0.41 | $0.41 | $0.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $602.56 / $912.01
| Professional | | $331.13 | $602.56 | $912.01 |