- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Facility | | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $371.54 / $575.44
| Professional | | $281.84 | $371.54 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $1,071.52
| Facility | | $645.65 | $645.65 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $602.56 / $724.44
| Professional | | $588.84 | $602.56 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $1,513.56 / $3,162.28
| Facility | | $398.11 | $1,513.56 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $933.25 / $1,230.27
| Professional | | $288.40 | $933.25 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $537.03 / $794.33
| Facility | | $323.59 | $537.03 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $1,023.29 / $1,230.27
| Professional | | $575.44 | $1,023.29 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $630.96 / $3,388.44
| Facility | | $323.59 | $630.96 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $426.58 / $724.44
| Professional | | $295.12 | $426.58 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $407.38
| Professional | | $54.95 | $70.79 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,023.29 / $1,023.29
| Facility | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $724.44 / $1,288.25
| Professional | | $457.09 | $724.44 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $1,000.00 / $1,995.26
| Professional | | $645.65 | $1,000.00 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $1,288.25 / $3,388.44
| Facility | | $398.11 | $1,288.25 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $575.44 / $4,168.69
| Professional | | $288.40 | $575.44 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $478.63 / $645.65
| Facility | | $316.23 | $478.63 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $316.23 / $549.54
| Professional | | $263.03 | $316.23 | $549.54 |