- 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 / $562.34 / $1,071.52
| Professional | | $478.63 | $562.34 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $165.96 / $2,398.83
| Facility | | $117.49 | $165.96 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $562.34 / $1,318.26
| Professional | | $125.89 | $562.34 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $562.34 / $602.56
| Facility | | $562.34 | $562.34 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $478.63 / $562.34
| Professional | | $60.26 | $478.63 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $575.44 / $1,071.52
| Facility | | $109.65 | $575.44 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $645.65 / $1,071.52
| Professional | | $478.63 | $645.65 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $87.10 / $891.25
| Professional | | $66.07 | $87.10 | $891.25 |
- 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 / $1,258.93
| Professional | | $741.31 | $776.25 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $489.78 / $812.83
| Facility | | $43.65 | $489.78 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $549.54 / $870.96
| Professional | | $512.86 | $549.54 | $870.96 |