- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $371.54 / $371.54
| Facility | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $371.54 / $407.38
| Professional | | $218.78 | $371.54 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $426.58
| Professional | | $380.19 | $380.19 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $346.74 / $346.74
| Facility | | $223.87 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $398.11
| Professional | | $251.19 | $251.19 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $338.84 / $426.58
| Professional | | $309.03 | $338.84 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $436.52 / $741.31
| Facility | | $208.93 | $436.52 | $741.31 |
- 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
- $208.93 / $380.19 / $407.38
| Facility | | $208.93 | $380.19 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $251.19 / $389.05
| Professional | | $208.93 | $251.19 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,388.44 / $3,388.44 / $3,801.89
| Professional | | $3,388.44 | $3,388.44 | $3,801.89 |