- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $371.54 / $371.54
| Facility | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $371.54 / $588.84
| Professional | | $208.93 | $371.54 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $602.56 / $1,023.29
| Facility | | $562.34 | $602.56 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $676.08 / $812.83
| Professional | | $645.65 | $676.08 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $436.52
| Facility | | $309.03 | $309.03 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $309.03 / $380.19
| Professional | | $263.03 | $309.03 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $316.23 / $660.69
| Facility | | $223.87 | $316.23 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $426.58 / $467.74
| Professional | | $407.38 | $426.58 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $446.68 / $457.09
| Professional | | $45.71 | $446.68 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $346.74
| Professional | | $331.13 | $331.13 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $645.65
| Professional | | $467.74 | $467.74 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $22.91 / $229.09 / $346.74
| Facility | | $22.91 | $229.09 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $302.00 / $467.74
| Professional | | $229.09 | $302.00 | $467.74 |