- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $630.96 / $630.96
| Facility | | $549.54 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $426.58 / $630.96
| Professional | | $323.59 | $426.58 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $912.01
| Facility | | $489.78 | $489.78 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $870.96 / $1,096.48
| Professional | | $489.78 | $870.96 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $870.96 / $1,047.13
| Professional | | $707.95 | $870.96 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $1,047.13 / $3,890.45
| Facility | | $549.54 | $1,047.13 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $562.34 / $1,348.96
| Professional | | $380.19 | $562.34 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $933.25 / $1,148.15
| Professional | | $891.25 | $933.25 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,348.96 / $1,348.96
| Professional | | $870.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $831.76 / $1,995.26
| Facility | | $371.54 | $831.76 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $436.52 / $758.58
| Professional | | $371.54 | $436.52 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $794.33 / $794.33
| Professional | | $630.96 | $794.33 | $794.33 |