- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $363.08
| Facility | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $363.08 / $2,630.27
| Professional | | $162.18 | $363.08 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $549.54 / $562.34
| Professional | | $501.19 | $549.54 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $645.65
| Facility | | $338.84 | $338.84 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $630.96 / $977.24
| Professional | | $338.84 | $630.96 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $630.96 / $2,570.40
| Facility | | $363.08 | $630.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $331.13 / $575.44
| Professional | | $190.55 | $331.13 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $630.96 / $1,548.82
| Professional | | $630.96 | $630.96 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,445.44 / $1,548.82
| Professional | | $794.33 | $1,445.44 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $380.19 / $575.44
| Facility | | $239.88 | $380.19 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $288.40 / $446.68
| Professional | | $208.93 | $288.40 | $446.68 |