- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $588.84 / $1,096.48
| Professional | | $478.63 | $588.84 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $165.96 / $2,454.71
| Facility | | $120.23 | $165.96 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $562.34 / $1,348.96
| Professional | | $128.82 | $562.34 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $602.56
| Facility | | $575.44 | $575.44 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $489.78 / $575.44
| Professional | | $60.26 | $489.78 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $630.96 / $1,096.48
| Facility | | $112.20 | $630.96 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $645.65 / $1,096.48
| Professional | | $478.63 | $645.65 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $89.13 / $912.01
| Professional | | $66.07 | $89.13 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $537.03 / $812.83
| Professional | | $537.03 | $537.03 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $776.25 / $1,288.25
| Professional | | $741.31 | $776.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $91.20 / $912.01
| Facility | | $50.12 | $91.20 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $112.20 / $912.01
| Professional | | $46.77 | $112.20 | $912.01 |