- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $371.54 / $371.54
| Facility | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $371.54 / $2,238.72
| Professional | | $165.96 | $371.54 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $562.34 / $575.44
| Professional | | $512.86 | $562.34 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $660.69
| Facility | | $380.19 | $380.19 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $660.69 / $1,000.00
| Professional | | $380.19 | $660.69 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $645.65 / $2,754.23
| Facility | | $371.54 | $645.65 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $295.12 / $588.84
| Professional | | $194.98 | $295.12 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $1,584.89
| Professional | | $645.65 | $645.65 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $660.69
| Facility | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,479.11 / $1,584.89
| Professional | | $812.83 | $1,479.11 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $302.00 / $602.56
| Facility | | $199.53 | $302.00 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $295.12 / $457.09
| Professional | | $213.80 | $295.12 | $457.09 |