- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $354.81 / $354.81
| Facility | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $346.74 / $380.19
| Professional | | $208.93 | $346.74 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $371.54 / $407.38
| Professional | | $371.54 | $371.54 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $363.08 / $363.08
| Facility | | $213.80 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $389.05
| Professional | | $269.15 | $269.15 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $269.15 / $363.08
| Professional | | $251.19 | $269.15 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $416.87 / $707.95
| Facility | | $208.93 | $416.87 | $707.95 |
- 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
- $234.42 / $363.08 / $389.05
| Facility | | $234.42 | $363.08 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $239.88 / $371.54
| Professional | | $199.53 | $239.88 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,162.28 / $3,162.28 / $4,786.30
| Professional | | $3,162.28 | $3,162.28 | $4,786.30 |