- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $363.08
| Facility | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $363.08 / $2,454.71
| Professional | | $154.88 | $363.08 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $549.54 / $549.54
| Professional | | $501.19 | $549.54 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $302.00 / $630.96
| Facility | | $302.00 | $302.00 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $707.95 / $954.99
| Professional | | $302.00 | $707.95 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $616.60 / $2,691.53
| Facility | | $363.08 | $616.60 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $316.23 / $588.84
| Professional | | $186.21 | $316.23 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $1,513.56
| Professional | | $616.60 | $616.60 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,412.54 / $1,513.56
| Professional | | $776.25 | $1,412.54 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $363.08 / $549.54
| Facility | | $281.84 | $363.08 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $281.84 / $446.68
| Professional | | $204.17 | $281.84 | $446.68 |