- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $2,454.71 / $4,570.88
| Facility | | $870.96 | $2,454.71 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $891.25 / $1,380.38
| Professional | | $758.58 | $891.25 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $4,897.79
| Facility | | $1,148.15 | $1,148.15 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $776.25
| Professional | | $467.74 | $467.74 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $977.24 / $1,096.48
| Professional | | $891.25 | $977.24 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $2,290.87 / $5,888.44
| Facility | | $1,174.90 | $2,290.87 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $707.95 / $1,202.26
| Professional | | $575.44 | $707.95 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,288.25 / $1,621.81
| Professional | | $1,148.15 | $1,288.25 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,148.15 / $1,949.84
| Facility | | $870.96 | $1,148.15 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $2,454.71
| Professional | | $758.58 | $758.58 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,380.38 / $10,000.00
| Facility | | $812.83 | $1,380.38 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,380.38 / $10,000.00
| Professional | | $812.83 | $1,380.38 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,148.15 / $1,380.38
| Facility | | $691.83 | $1,148.15 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $575.44 / $1,288.25
| Professional | | $489.78 | $575.44 | $1,288.25 |