- 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
- $223.87 / $316.23 / $467.74
| Professional | | $223.87 | $316.23 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $407.38 / $446.68
| Professional | | $407.38 | $407.38 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $389.05 / $389.05
| Facility | | $234.42 | $389.05 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $281.84 / $416.87
| Professional | | $281.84 | $281.84 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $263.03 / $331.13
| Professional | | $245.47 | $263.03 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $467.74 / $758.58
| Facility | | $213.80 | $467.74 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $245.47 / $436.52
| Facility | | $186.21 | $245.47 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $263.03 / $371.54
| Professional | | $204.17 | $263.03 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,630.78 / $3,630.78 / $3,715.35
| Professional | | $3,630.78 | $3,630.78 | $3,715.35 |