- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $380.19
| Facility | | $263.03 | $263.03 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $263.03 / $380.19
| Professional | | $177.83 | $263.03 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $316.23 / $467.74
| Facility | | $316.23 | $316.23 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $630.96 / $794.33
| Professional | | $316.23 | $630.96 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $537.03 / $562.34
| Professional | | $398.11 | $537.03 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $537.03 / $2,187.76
| Facility | | $269.15 | $537.03 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $269.15 / $707.95
| Professional | | $199.53 | $269.15 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $478.63 / $630.96
| Professional | | $457.09 | $478.63 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $467.74
| Facility | | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $707.95 / $707.95
| Professional | | $478.63 | $707.95 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $426.58 / $1,096.48
| Facility | | $162.18 | $426.58 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $208.93 / $457.09
| Professional | | $199.53 | $208.93 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $416.87 / $416.87
| Professional | | $323.59 | $416.87 | $416.87 |