- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $588.84 / $954.99
| Professional | | $275.42 | $588.84 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $741.31 / $1,778.28
| Professional | | $741.31 | $741.31 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $630.96 / $831.76
| Facility | | $83.18 | $630.96 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $630.96 / $831.76
| Professional | | $83.18 | $630.96 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $616.60
| Facility | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $616.60 / $741.31
| Professional | | $524.81 | $616.60 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $676.08 / $1,023.29
| Professional | | $512.86 | $676.08 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $616.60 / $831.76
| Professional | | $588.84 | $616.60 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $323.59 / $562.34
| Facility | | $38.90 | $323.59 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $562.34 / $1,122.02
| Professional | | $331.13 | $562.34 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $588.84
| Facility | | $575.44 | $575.44 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $588.84 / $831.76
| Professional | | $588.84 | $588.84 | $831.76 |