- 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
- $213.80 / $295.12 / $371.54
| Professional | | $213.80 | $295.12 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $489.78
| Facility | | $416.87 | $416.87 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $416.87
| Professional | | $380.19 | $380.19 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Facility | | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $338.84
| Professional | | $234.42 | $234.42 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $251.19 / $331.13
| Professional | | $234.42 | $251.19 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $407.38 / $758.58
| Facility | | $177.83 | $407.38 | $758.58 |
- 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
- $186.21 / $331.13 / $407.38
| Facility | | $186.21 | $331.13 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $251.19 / $354.81
| Professional | | $194.98 | $251.19 | $354.81 |
- 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
- $2,570.40 / $2,570.40 / $3,630.78
| Professional | | $2,570.40 | $2,570.40 | $3,630.78 |