- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $537.03 / $537.03
| Facility | | $537.03 | $537.03 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $977.24 / $2,137.96
| Professional | | $537.03 | $977.24 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $288.40 / $2,398.83
| Facility | | $144.54 | $288.40 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $1,380.38 / $2,089.30
| Professional | | $208.93 | $1,380.38 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $114.82
| Facility | | $109.65 | $109.65 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $109.65
| Professional | | $93.33 | $93.33 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $588.84 / $2,137.96
| Facility | | $138.04 | $588.84 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $977.24 / $2,137.96
| Professional | | $537.03 | $977.24 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $138.04 / $1,445.44
| Professional | | $30.20 | $138.04 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $2,089.30
| Professional | | $1,380.38 | $1,380.38 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,995.26 / $1,995.26
| Professional | | $1,548.82 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $128.82 / $954.99
| Facility | | $83.18 | $128.82 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $83.18 / $891.25
| Professional | | $75.86 | $83.18 | $891.25 |