- 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
- $478.63 / $616.60 / $1,122.02
| Professional | | $478.63 | $616.60 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $1,995.26 / $1,995.26
| Facility | | $199.53 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $616.60 / $1,445.44
| Professional | | $138.04 | $616.60 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $645.65
| Facility | | $616.60 | $616.60 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $524.81 / $630.96
| Professional | | $66.07 | $524.81 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $562.34 / $977.24
| Facility | | $93.33 | $562.34 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $616.60 / $1,122.02
| Professional | | $478.63 | $616.60 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $87.10 / $891.25
| Professional | | $66.07 | $87.10 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $588.84 / $616.60
| Professional | | $588.84 | $588.84 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $1,288.25
| Professional | | $851.14 | $851.14 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $371.54 / $562.34
| Facility | | $46.77 | $371.54 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $416.87 / $562.34
| Professional | | $354.81 | $416.87 | $562.34 |