- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $891.25 / $1,174.90
| Professional | | $575.44 | $891.25 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $954.99 / $1,698.24
| Facility | | $95.50 | $954.99 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $776.25 / $1,230.27
| Professional | | $114.82 | $776.25 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $141.25
| Facility | | $134.90 | $134.90 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $114.82 / $134.90
| Professional | | $77.62 | $114.82 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $524.81 / $891.25
| Facility | | $109.65 | $524.81 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $891.25 / $1,174.90
| Professional | | $575.44 | $891.25 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $74.13 / $758.58
| Professional | | $56.23 | $74.13 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $741.31 / $776.25
| Professional | | $741.31 | $741.31 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,071.52 / $1,174.90
| Professional | | $794.33 | $1,071.52 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $338.84 / $758.58
| Facility | | $38.02 | $338.84 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $446.68 / $707.95
| Professional | | $380.19 | $446.68 | $707.95 |