- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $309.03
| Facility | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $288.40 / $331.13
| Professional | | $181.97 | $288.40 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $354.81
| Professional | | $323.59 | $323.59 | $354.81 |
- 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
- $239.88 / $239.88 / $346.74
| Professional | | $239.88 | $239.88 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $239.88 / $281.84
| Professional | | $223.87 | $239.88 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $354.81 / $630.96
| Facility | | $173.78 | $354.81 | $630.96 |
- 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
- $173.78 / $316.23 / $338.84
| Facility | | $173.78 | $316.23 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $208.93 / $323.59
| Professional | | $173.78 | $208.93 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,818.38 / $2,818.38 / $3,162.28
| Professional | | $2,818.38 | $2,818.38 | $3,162.28 |