- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $1,230.27 / $2,511.89
| Facility | | $363.08 | $1,230.27 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $416.87 / $645.65
| Professional | | $331.13 | $416.87 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $50.12 / $50.12
| Professional | | $50.12 | $50.12 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $512.86 / $602.56
| Facility | | $446.68 | $512.86 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.96 / $512.86 / $512.86
| Professional | | $10.96 | $512.86 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $446.68 / $2,089.30
| Facility | | $302.00 | $446.68 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $363.08 / $870.96
| Professional | | $239.88 | $363.08 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $302.00 / $436.52
| Professional | | $302.00 | $302.00 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $812.83
| Professional | | $338.84 | $338.84 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $457.09 / $512.86
| Facility | | $213.80 | $457.09 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $213.80 / $691.83
| Professional | | $177.83 | $213.80 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $302.00 / $512.86
| Professional | | $302.00 | $302.00 | $512.86 |