- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $977.24 / $977.24
| Facility | | $977.24 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $977.24 / $1,348.96
| Professional | | $588.84 | $977.24 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,698.24 / $2,187.76
| Professional | | $1,513.56 | $1,698.24 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $109.65
| Professional | | $93.33 | $93.33 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $75.86 / $199.53
| Professional | | $60.26 | $75.86 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $190.55 / $194.98
| Facility | | $173.78 | $190.55 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $194.98 / $194.98
| Professional | | $173.78 | $194.98 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $169.82 / $1,698.24
| Facility | | $162.18 | $169.82 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $223.87 / $1,698.24
| Professional | | $162.18 | $223.87 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,698.24 / $2,187.76
| Professional | | $1,445.44 | $1,698.24 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $128.82 / $1,122.02
| Facility | | $75.86 | $128.82 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $117.49 / $776.25
| Professional | | $77.62 | $117.49 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $954.99 / $954.99
| Professional | | $79.43 | $954.99 | $954.99 |