- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $489.78
| Facility | | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $489.78 / $2,818.38
| Professional | | $208.93 | $489.78 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $741.31 / $758.58
| Professional | | $676.08 | $741.31 | $758.58 |
- 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 / $870.96 / $1,318.26
| Professional | | $489.78 | $870.96 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $851.14 / $3,311.31
| Facility | | $489.78 | $851.14 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $436.52 / $776.25
| Professional | | $257.04 | $436.52 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $2,089.30
| Professional | | $851.14 | $851.14 | $2,089.30 |
- 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
- $1,071.52 / $1,949.84 / $2,089.30
| Professional | | $1,071.52 | $1,949.84 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $489.78 / $758.58
| Facility | | $295.12 | $489.78 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $389.05 / $602.56
| Professional | | $281.84 | $389.05 | $602.56 |