- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $660.69
| Facility | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $776.25
| Professional | | $660.69 | $660.69 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $245.47 / $302.00
| Facility | | $190.55 | $245.47 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $776.25 / $933.25
| Professional | | $467.74 | $776.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $676.08 / $1,380.38
| Professional | | $275.42 | $676.08 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $870.96 / $2,238.72
| Facility | | $724.44 | $870.96 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $724.44 / $1,288.25
| Professional | | $724.44 | $724.44 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $870.96 / $2,238.72
| Professional | | $812.83 | $870.96 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $245.47 / $302.00
| Facility | | $204.17 | $245.47 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,202.26 / $1,288.25
| Professional | | $1,202.26 | $1,202.26 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.72 / $724.44 / $1,174.90
| Facility | | $0.72 | $724.44 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $724.44
| Professional | | $125.89 | $125.89 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $660.69
| Facility | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |