- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $354.81 / $354.81
| Facility | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $269.15 / $354.81
| Professional | | $181.97 | $269.15 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $338.84
| Professional | | $309.03 | $309.03 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $251.19 / $251.19
| Facility | | $177.83 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $323.59
| Professional | | $181.97 | $181.97 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $223.87 / $309.03
| Professional | | $208.93 | $223.87 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $354.81 / $602.56
| Facility | | $173.78 | $354.81 | $602.56 |
- 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
- $151.36 / $199.53 / $331.13
| Facility | | $151.36 | $199.53 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $199.53 / $302.00
| Professional | | $154.88 | $199.53 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $3,019.95 / $3,801.89
| Professional | | $3,019.95 | $3,019.95 | $3,801.89 |