- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $831.76 / $831.76
| Facility | | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $489.78 / $831.76
| Professional | | $354.81 | $489.78 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $741.31 / $812.83
| Professional | | $741.31 | $741.31 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $501.19 / $588.84
| Facility | | $426.58 | $501.19 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $616.60
| Professional | | $363.08 | $363.08 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $389.05 / $562.34
| Professional | | $363.08 | $389.05 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $831.76 / $1,318.26
| Facility | | $338.84 | $831.76 | $1,318.26 |
- 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
- $288.40 / $389.05 / $776.25
| Facility | | $288.40 | $389.05 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $457.09 / $660.69
| Professional | | $323.59 | $457.09 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,248.07 / $5,248.07 / $5,754.40
| Professional | | $5,248.07 | $5,248.07 | $5,754.40 |