- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $602.56 / $602.56
| Facility | | $346.74 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $602.56 / $602.56
| Professional | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $87.10 / $177.83
| Professional | | $28.18 | $87.10 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $194.98 / $194.98
| Facility | | $158.49 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Professional | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $977.24 / $977.24
| Professional | | $831.76 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $1,122.02
| Professional | | $489.78 | $489.78 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $112.20 / $151.36
| Professional | | $50.12 | $112.20 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $295.12 / $1,122.02
| Facility | | $37.15 | $295.12 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $398.11 / $1,513.56
| Professional | | $54.95 | $398.11 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $1,148.15
| Professional | | $1,148.15 | $1,148.15 | $1,148.15 |