- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $489.78 / $1,479.11
| Facility | | $112.20 | $489.78 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $316.23 / $524.81
| Professional | | $302.00 | $316.23 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $309.03 / $467.74
| Professional | | $229.09 | $309.03 | $467.74 |
- 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
- $218.78 / $407.38 / $512.86
| Professional | | $218.78 | $407.38 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $660.69 / $1,202.26
| Facility | | $501.19 | $660.69 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $1,995.26 / $1,995.26
| Professional | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $371.54 / $446.68
| Professional | | $218.78 | $371.54 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $186.21 / $239.88
| Professional | | $141.25 | $186.21 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $512.86 / $691.83
| Facility | | $363.08 | $512.86 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $446.68
| Professional | | $363.08 | $363.08 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $537.03 / $537.03
| Professional | | $512.86 | $537.03 | $537.03 |