- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $851.14 / $851.14
| Facility | | $549.54 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $524.81 / $794.33
| Professional | | $389.05 | $524.81 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $1,071.52 / $1,348.96
| Professional | | $660.69 | $1,071.52 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $151.36
| Professional | | $87.10 | $87.10 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $741.31 / $4,168.69
| Facility | | $64.57 | $741.31 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $389.05 / $1,047.13
| Professional | | $199.53 | $389.05 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $812.83 / $2,187.76
| Professional | | $309.03 | $812.83 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $1,174.90 / $1,174.90
| Professional | | $309.03 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $288.40 / $512.86
| Facility | | $33.11 | $288.40 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $389.05 / $741.31
| Professional | | $338.84 | $389.05 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $870.96 / $870.96
| Professional | | $691.83 | $870.96 | $870.96 |