- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $724.44 / $724.44
| Facility | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $512.86 / $724.44
| Professional | | $346.74 | $512.86 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $812.83
| Facility | | $676.08 | $676.08 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $630.96 / $691.83
| Professional | | $630.96 | $630.96 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $630.96 / $630.96
| Facility | | $371.54 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $457.09 / $630.96
| Professional | | $457.09 | $457.09 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $389.05 / $501.19
| Professional | | $363.08 | $389.05 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $724.44 / $1,174.90
| Facility | | $338.84 | $724.44 | $1,174.90 |
- 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
- $281.84 / $380.19 / $676.08
| Facility | | $281.84 | $380.19 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $407.38 / $588.84
| Professional | | $316.23 | $407.38 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $4,073.80 / $4,073.80
| Facility | | $4,073.80 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,370.32 / $5,370.32 / $6,760.83
| Professional | | $5,370.32 | $5,370.32 | $6,760.83 |