- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $524.81 / $524.81
| Facility | | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $512.86 / $575.44
| Professional | | $309.03 | $512.86 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $537.03 / $602.56
| Professional | | $537.03 | $537.03 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $457.09 / $457.09
| Facility | | $316.23 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $549.54
| Professional | | $331.13 | $331.13 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $426.58 / $478.63
| Professional | | $389.05 | $426.58 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $588.84 / $1,023.29
| Facility | | $295.12 | $588.84 | $1,023.29 |
- 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
- $295.12 / $537.03 / $575.44
| Facility | | $295.12 | $537.03 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $354.81 / $549.54
| Professional | | $295.12 | $354.81 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,786.30 / $4,786.30 / $5,370.32
| Professional | | $4,786.30 | $4,786.30 | $5,370.32 |