- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $288.40
| Facility | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $288.40 / $1,995.26
| Professional | | $117.49 | $288.40 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $436.52 / $446.68
| Professional | | $398.11 | $436.52 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $512.86
| Facility | | $295.12 | $295.12 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $524.81 / $776.25
| Professional | | $295.12 | $524.81 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $501.19 / $1,905.46
| Facility | | $288.40 | $501.19 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $239.88 / $457.09
| Professional | | $151.36 | $239.88 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $501.19 / $1,230.27
| Professional | | $501.19 | $501.19 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,148.15 / $1,230.27
| Professional | | $630.96 | $1,148.15 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $275.42 / $416.87
| Facility | | $229.09 | $275.42 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $229.09 / $354.81
| Professional | | $165.96 | $229.09 | $354.81 |