- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $489.78
| Facility | | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $457.09 / $562.34
| Professional | | $446.68 | $457.09 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Facility | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $141.25
| Professional | | $125.89 | $125.89 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $588.84
| Facility | | $169.82 | $169.82 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $131.83
| Professional | | $125.89 | $125.89 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $1,000.00 / $1,584.89
| Facility | | $380.19 | $1,000.00 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,348.96 / $1,737.80
| Professional | | $1,174.90 | $1,348.96 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $812.83
| Facility | | $446.68 | $446.68 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,148.15 / $1,148.15
| Facility | | $724.44 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $724.44 / $724.44
| Professional | | $588.84 | $724.44 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Facility | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $125.89 / $141.25
| Professional | | $123.03 | $125.89 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $478.63 / $1,122.02
| Facility | | $316.23 | $478.63 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $478.63
| Professional | | $125.89 | $125.89 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $154.88 / $295.12
| Professional | | $134.90 | $154.88 | $295.12 |