- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $3,019.95 / $5,754.40
| Facility | | $524.81 | $3,019.95 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $616.60 / $1,445.44
| Professional | | $416.87 | $616.60 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $416.87 / $416.87
| Professional | | $380.19 | $416.87 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,819.70 / $3,981.07
| Facility | | $676.08 | $1,819.70 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $524.81 / $851.14
| Professional | | $380.19 | $524.81 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $645.65 / $912.01
| Professional | | $457.09 | $645.65 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $724.44 / $724.44
| Facility | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $575.44 / $1,000.00
| Professional | | $389.05 | $575.44 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $660.69 / $1,819.70
| Facility | | $407.38 | $660.69 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $954.99 / $4,073.80
| Professional | | $512.86 | $954.99 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,148.15 / $2,691.53
| Facility | | $954.99 | $1,148.15 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $575.44 / $1,000.00
| Professional | | $398.11 | $575.44 | $1,000.00 |