- 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
- $194.98 / $309.03 / $354.81
| Professional | | $194.98 | $309.03 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $380.19
| Professional | | $346.74 | $346.74 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $281.84 / $281.84
| Facility | | $199.53 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $331.13
| Professional | | $204.17 | $204.17 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $257.04 / $288.40
| Professional | | $239.88 | $257.04 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $371.54 / $645.65
| Facility | | $186.21 | $371.54 | $645.65 |
- 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 / $323.59 / $363.08
| Facility | | $208.93 | $323.59 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $223.87 / $331.13
| Professional | | $177.83 | $223.87 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |