- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $831.76 / $831.76
| Facility | | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,621.81 / $1,737.80
| Professional | | $831.76 | $1,621.81 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $134.90 / $208.93
| Facility | | $125.89 | $134.90 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $117.49
| Professional | | $89.13 | $89.13 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $190.55 / $302.00
| Facility | | $144.54 | $190.55 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $169.82
| Professional | | $125.89 | $125.89 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,659.59 / $2,398.83
| Facility | | $831.76 | $1,659.59 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $316.23
| Professional | | $109.65 | $109.65 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $194.98 / $245.47
| Professional | | $0.60 | $194.98 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $389.05 / $602.56
| Facility | | $102.33 | $389.05 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $323.59
| Professional | | $125.89 | $125.89 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,370.32 / $5,370.32 / $6,918.31
| Professional | | $5,370.32 | $5,370.32 | $6,918.31 |