- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $616.60
| Facility | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $562.34 / $691.83
| Professional | | $549.54 | $562.34 | $691.83 |
- 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 / $2,137.96 / $3,311.31
| Facility | | $380.19 | $2,137.96 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,511.89 / $4,365.16
| Professional | | $2,137.96 | $2,511.89 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $50.12 / $60.26
| Professional | | $39.81 | $50.12 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $616.60 / $1,096.48
| Facility | | $549.54 | $616.60 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $2,238.72 / $2,951.21
| Facility | | $2,238.72 | $2,238.72 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,951.21 / $2,951.21 / $3,090.30
| Professional | | $2,951.21 | $2,951.21 | $3,090.30 |
- 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
- $102.33 / $102.33 / $2,818.38
| Facility | | $102.33 | $102.33 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $2,818.38
| Professional | | $125.89 | $125.89 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $154.88 / $295.12
| Professional | | $134.90 | $154.88 | $295.12 |