- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $912.01 / $1,096.48
| Professional | | $602.56 | $912.01 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,584.89 / $3,311.31
| Professional | | $933.25 | $1,584.89 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,230.27 / $1,659.59
| Professional | | $1,230.27 | $1,230.27 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $602.56 / $912.01
| Facility | | $77.62 | $602.56 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $537.03 / $933.25
| Facility | | $67.61 | $537.03 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $1,174.90 / $3,090.30
| Professional | | $645.65 | $1,174.90 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $54.95 / $70.79
| Professional | | $32.36 | $54.95 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $194.98 / $1,862.09
| Professional | | $93.33 | $194.98 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $5,888.44
| Facility | | $190.55 | $190.55 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $5,888.44
| Professional | | $1,621.81 | $1,621.81 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $1,023.29 / $2,137.96
| Professional | | $398.11 | $1,023.29 | $2,137.96 |