- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $331.13
| Facility | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $331.13 / $794.33
| Professional | | $169.82 | $331.13 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $288.40
| Professional | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $316.23 / $380.19
| Facility | | $316.23 | $316.23 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $309.03
| Professional | | $288.40 | $288.40 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $208.93 / $208.93
| Facility | | $107.15 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $154.88 / $223.87
| Professional | | $151.36 | $154.88 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $190.55 / $245.47
| Professional | | $177.83 | $190.55 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $331.13 / $549.54
| Facility | | $125.89 | $331.13 | $549.54 |
- 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
- $114.82 / $169.82 / $309.03
| Facility | | $114.82 | $169.82 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $186.21 / $269.15
| Professional | | $141.25 | $186.21 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $1,949.84 / $2,754.23
| Professional | | $1,949.84 | $1,949.84 | $2,754.23 |