- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $501.19 / $501.19
| Facility | | $23.99 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $436.52 / $501.19
| Professional | | $288.40 | $436.52 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $512.86 / $562.34
| Professional | | $512.86 | $512.86 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $416.87 / $416.87
| Facility | | $302.00 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $524.81
| Professional | | $309.03 | $309.03 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $426.58 / $446.68
| Professional | | $398.11 | $426.58 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $549.54 / $977.24
| Facility | | $281.84 | $549.54 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $501.19 / $549.54
| Facility | | $331.13 | $501.19 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $331.13 / $512.86
| Professional | | $281.84 | $331.13 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,365.16 / $4,365.16 / $5,128.61
| Professional | | $4,365.16 | $4,365.16 | $5,128.61 |