- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $398.11
| Facility | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $398.11 / $3,630.78
| Professional | | $199.53 | $398.11 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $537.03 / $537.03
| Professional | | $537.03 | $537.03 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $602.56 / $616.60
| Professional | | $549.54 | $602.56 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $524.81 / $707.95
| Facility | | $524.81 | $524.81 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $870.96 / $1,202.26
| Professional | | $524.81 | $870.96 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $707.95 / $3,388.44
| Facility | | $398.11 | $707.95 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $309.03 / $676.08
| Professional | | $208.93 | $309.03 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $691.83 / $1,698.24
| Professional | | $691.83 | $691.83 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $707.95
| Facility | | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,548.82 / $1,698.24
| Professional | | $870.96 | $1,548.82 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $371.54 / $724.44
| Facility | | $239.88 | $371.54 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $309.03 / $489.78
| Professional | | $223.87 | $309.03 | $489.78 |