- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $575.44
| Facility | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $575.44 / $724.44
| Professional | | $478.63 | $575.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $724.44 / $724.44
| Professional | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $676.08
| Professional | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $457.09 / $676.08
| Facility | | $457.09 | $457.09 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $457.09
| Professional | | $389.05 | $389.05 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $933.25 / $1,318.26
| Professional | | $831.76 | $933.25 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $977.24
| Professional | | $489.78 | $489.78 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $562.34 / $1,096.48
| Facility | | $269.15 | $562.34 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $131.83 / $1,148.15
| Facility | | $61.66 | $131.83 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $131.83 / $1,148.15
| Professional | | $61.66 | $131.83 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $467.74 / $741.31
| Facility | | $54.95 | $467.74 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $549.54 / $1,000.00
| Professional | | $467.74 | $549.54 | $1,000.00 |