- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $741.31 / $741.31
| Facility | | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $562.34 / $741.31
| Professional | | $371.54 | $562.34 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $691.83 / $831.76
| Facility | | $691.83 | $691.83 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $707.95
| Professional | | $645.65 | $645.65 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $524.81 / $524.81
| Facility | | $371.54 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $660.69
| Professional | | $380.19 | $380.19 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $426.58 / $588.84
| Professional | | $389.05 | $426.58 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $741.31 / $1,258.93
| Facility | | $380.19 | $741.31 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $416.87 / $691.83
| Facility | | $316.23 | $416.87 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $416.87 / $630.96
| Professional | | $323.59 | $416.87 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,570.88 / $4,570.88 / $4,570.88
| Facility | | $4,570.88 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,623.41 / $5,623.41 / $8,317.64
| Professional | | $5,623.41 | $5,623.41 | $8,317.64 |