- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $575.44
| Facility | | $489.78 | $489.78 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $446.68 / $954.99
| Professional | | $338.84 | $446.68 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $870.96
| Facility | | $489.78 | $489.78 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $954.99 / $1,202.26
| Professional | | $489.78 | $954.99 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $870.96 / $954.99
| Professional | | $691.83 | $870.96 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $977.24 / $3,715.35
| Facility | | $524.81 | $977.24 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $512.86 / $1,288.25
| Professional | | $363.08 | $512.86 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $891.25 / $1,096.48
| Professional | | $851.14 | $891.25 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $870.96 / $870.96
| Facility | | $870.96 | $870.96 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,288.25 / $1,288.25
| Professional | | $831.76 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $831.76 / $1,905.46
| Facility | | $295.12 | $831.76 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $389.05 / $831.76
| Professional | | $363.08 | $389.05 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $741.31 / $741.31
| Professional | | $575.44 | $741.31 | $741.31 |