- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $295.12
| Facility | | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $295.12 / $2,398.83
| Professional | | $131.83 | $295.12 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $446.68 / $446.68
| Professional | | $407.38 | $446.68 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $512.86
| Facility | | $275.42 | $275.42 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $562.34 / $794.33
| Professional | | $275.42 | $562.34 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $501.19 / $2,238.72
| Facility | | $295.12 | $501.19 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $229.09 / $457.09
| Professional | | $151.36 | $229.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $501.19 / $1,230.27
| Professional | | $501.19 | $501.19 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,148.15 / $1,230.27
| Professional | | $630.96 | $1,148.15 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $245.47 / $478.63
| Facility | | $158.49 | $245.47 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $229.09 / $354.81
| Professional | | $165.96 | $229.09 | $354.81 |