- 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
- $208.93 / $263.03 / $371.54
| Professional | | $208.93 | $263.03 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $501.19
| Facility | | $416.87 | $416.87 | $501.19 |
- 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
- $223.87 / $281.84 / $309.03
| Facility | | $223.87 | $281.84 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $323.59
| Professional | | $204.17 | $204.17 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $257.04 / $269.15
| Professional | | $234.42 | $257.04 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $380.19 / $676.08
| Facility | | $190.55 | $380.19 | $676.08 |
- 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
- $199.53 / $302.00 / $407.38
| Facility | | $199.53 | $302.00 | $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
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $2,630.27 / $3,467.37
| Professional | | $2,630.27 | $2,630.27 | $3,467.37 |