- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $562.34 / $4,365.16
| Professional | | $263.03 | $562.34 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $851.14 / $851.14
| Professional | | $776.25 | $851.14 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $691.83 / $977.24
| Facility | | $691.83 | $691.83 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,202.26 / $1,584.89
| Professional | | $691.83 | $1,202.26 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $977.24 / $4,466.84
| Facility | | $562.34 | $977.24 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $537.03 / $870.96
| Professional | | $288.40 | $537.03 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $954.99 / $2,344.23
| Professional | | $954.99 | $954.99 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $977.24 / $977.24
| Facility | | $977.24 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $2,187.76 / $2,344.23
| Professional | | $1,202.26 | $2,187.76 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $616.60 / $954.99
| Facility | | $398.11 | $616.60 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $436.52 / $691.83
| Professional | | $316.23 | $436.52 | $691.83 |