- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $446.68
| Facility | | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $446.68 / $3,235.94
| Professional | | $208.93 | $446.68 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $691.83 / $691.83
| Professional | | $616.60 | $691.83 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $794.33
| Facility | | $398.11 | $398.11 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $977.24 / $1,230.27
| Professional | | $398.11 | $977.24 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $794.33 / $3,630.78
| Facility | | $446.68 | $794.33 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $426.58 / $741.31
| Professional | | $234.42 | $426.58 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $776.25 / $1,905.46
| Professional | | $776.25 | $776.25 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,778.28 / $1,905.46
| Professional | | $977.24 | $1,778.28 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $489.78 / $741.31
| Facility | | $371.54 | $489.78 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $354.81 / $549.54
| Professional | | $257.04 | $354.81 | $549.54 |