- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $338.84
| Facility | | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $295.12 / $338.84
| Professional | | $194.98 | $295.12 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $416.87
| Professional | | $223.87 | $223.87 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $446.68
| Facility | | $380.19 | $380.19 | $446.68 |
- 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
- $204.17 / $295.12 / $295.12
| Facility | | $204.17 | $295.12 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $338.84
| Professional | | $213.80 | $213.80 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $257.04 / $281.84
| Professional | | $239.88 | $257.04 | $281.84 |
- 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
- $204.17 / $316.23 / $371.54
| Facility | | $204.17 | $316.23 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $229.09 / $323.59
| Professional | | $177.83 | $229.09 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $3,019.95 / $3,162.28
| Professional | | $3,019.95 | $3,019.95 | $3,162.28 |