- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $812.83 / $1,148.15
| Professional | | $512.86 | $812.83 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $933.25 / $1,659.59
| Facility | | $93.33 | $933.25 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $776.25 / $1,096.48
| Professional | | $104.71 | $776.25 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $446.68
| Facility | | $426.58 | $426.58 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $363.08 / $426.58
| Professional | | $72.44 | $363.08 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $489.78 / $812.83
| Facility | | $104.71 | $489.78 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $812.83 / $1,148.15
| Professional | | $512.86 | $812.83 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $72.44 / $741.31
| Professional | | $54.95 | $72.44 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $724.44 / $776.25
| Professional | | $724.44 | $724.44 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,047.13 / $1,047.13
| Professional | | $776.25 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $302.00 / $691.83
| Facility | | $34.67 | $302.00 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $407.38 / $645.65
| Professional | | $346.74 | $407.38 | $645.65 |