- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $549.54 / $549.54
| Facility | | $128.82 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $660.69
| Professional | | $549.54 | $549.54 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $602.56 / $630.96
| Facility | | $467.74 | $602.56 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $602.56 / $630.96
| Professional | | $588.84 | $602.56 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $208.93 / $229.09
| Facility | | $144.54 | $208.93 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $1,288.25 / $3,388.44
| Professional | | $125.89 | $1,288.25 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $3,388.44 / $5,370.32
| Facility | | $2,398.83 | $3,388.44 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $2,818.38 / $3,388.44
| Professional | | $2,691.53 | $2,818.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $3,388.44 / $3,388.44
| Professional | | $1,230.27 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $208.93 / $309.03
| Facility | | $169.82 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $3,235.94 / $7,079.46
| Professional | | $1,288.25 | $3,235.94 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $3,388.44 / $7,413.10
| Facility | | $102.33 | $3,388.44 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $141.25 / $2,818.38
| Professional | | $125.89 | $141.25 | $2,818.38 |