- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $309.03 / $616.60
| Facility | | $213.80 | $309.03 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $204.17 / $309.03
| Professional | | $151.36 | $204.17 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $354.81
| Facility | | $295.12 | $295.12 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $288.40
| Professional | | $269.15 | $269.15 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Facility | | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $229.09
| Professional | | $154.88 | $154.88 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $177.83 / $234.42
| Professional | | $165.96 | $177.83 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $309.03 / $524.81
| Facility | | $141.25 | $309.03 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $346.74 / $363.08
| Professional | | $0.60 | $346.74 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $158.49 / $288.40
| Facility | | $107.15 | $158.49 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $173.78 / $251.19
| Professional | | $131.83 | $173.78 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $1,819.70 / $2,570.40
| Professional | | $1,819.70 | $1,819.70 | $2,570.40 |