- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $309.03
| Facility | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $309.03 / $2,238.72
| Professional | | $134.90 | $309.03 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $478.63 / $478.63
| Professional | | $426.58 | $478.63 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $549.54
| Facility | | $323.59 | $323.59 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $588.84 / $831.76
| Professional | | $323.59 | $588.84 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $537.03 / $2,238.72
| Facility | | $309.03 | $537.03 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $275.42 / $467.74
| Professional | | $162.18 | $275.42 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $537.03 / $1,318.26
| Professional | | $537.03 | $537.03 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,230.27 / $1,318.26
| Professional | | $676.08 | $1,230.27 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $323.59 / $478.63
| Facility | | $275.42 | $323.59 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $245.47 / $380.19
| Professional | | $177.83 | $245.47 | $380.19 |