- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $331.13
| Facility | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $331.13 / $2,187.76
| Professional | | $131.83 | $331.13 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $501.19 / $512.86
| Professional | | $457.09 | $501.19 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $302.00 / $588.84
| Facility | | $302.00 | $302.00 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $575.44 / $891.25
| Professional | | $302.00 | $575.44 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $575.44 / $2,137.96
| Facility | | $331.13 | $575.44 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $269.15 / $524.81
| Professional | | $173.78 | $269.15 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $1,412.54
| Professional | | $575.44 | $575.44 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $588.84 / $588.84
| Facility | | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,318.26 / $1,412.54
| Professional | | $724.44 | $1,318.26 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $309.03 / $467.74
| Facility | | $251.19 | $309.03 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $263.03 / $407.38
| Professional | | $186.21 | $263.03 | $407.38 |