- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $281.84 / $281.84
| Facility | | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $204.17 / $281.84
| Professional | | $141.25 | $204.17 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $245.47 / $269.15
| Professional | | $245.47 | $245.47 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $269.15 / $269.15
| Facility | | $144.54 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $275.42
| Professional | | $194.98 | $194.98 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $162.18 / $213.80
| Professional | | $151.36 | $162.18 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $281.84 / $478.63
| Facility | | $134.90 | $281.84 | $478.63 |
- 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
- $123.03 / $162.18 / $263.03
| Facility | | $123.03 | $162.18 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $162.18 / $245.47
| Professional | | $123.03 | $162.18 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,511.89 / $2,511.89 / $2,951.21
| Professional | | $2,511.89 | $2,511.89 | $2,951.21 |