- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $389.05 / $602.56
| Professional | | $288.40 | $389.05 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $630.96 / $630.96
| Professional | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $524.81 / $575.44
| Professional | | $524.81 | $524.81 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $416.87 / $416.87
| Facility | | $144.54 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $489.78
| Professional | | $309.03 | $309.03 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $338.84 / $446.68
| Professional | | $316.23 | $338.84 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $602.56 / $1,000.00
| Facility | | $281.84 | $602.56 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $660.69 / $707.95
| Professional | | $0.60 | $660.69 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $302.00 / $562.34
| Facility | | $204.17 | $302.00 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $338.84 / $478.63
| Professional | | $251.19 | $338.84 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,235.94 / $3,235.94 / $3,235.94
| Facility | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,467.37 / $3,467.37 / $5,011.87
| Professional | | $3,467.37 | $3,467.37 | $5,011.87 |