- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $2,041.74 / $4,570.88
| Facility | | $588.84 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $724.44 / $1,202.26
| Professional | | $562.34 | $724.44 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $512.86 / $512.86
| Professional | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $851.14 / $1,000.00
| Facility | | $741.31 | $851.14 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.96 / $851.14 / $851.14
| Professional | | $10.96 | $851.14 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $501.19 / $3,467.37
| Facility | | $338.84 | $501.19 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $691.83 / $1,513.56
| Professional | | $407.38 | $691.83 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $512.86 / $1,148.15
| Professional | | $512.86 | $512.86 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $117.49 / $194.98
| Professional | | $107.15 | $117.49 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $758.58 / $851.14
| Facility | | $354.81 | $758.58 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $354.81 / $1,122.02
| Professional | | $295.12 | $354.81 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $851.14 / $851.14
| Professional | | $107.15 | $851.14 | $851.14 |