- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $741.31 / $2,818.38
| Facility | | $218.78 | $741.31 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $724.44 / $1,258.93
| Professional | | $602.56 | $724.44 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $2,570.40 / $2,570.40
| Facility | | $1,905.46 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $851.14 / $1,513.56
| Professional | | $724.44 | $851.14 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $1,862.09 / $3,890.45
| Facility | | $645.65 | $1,862.09 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $398.11 / $1,148.15
| Professional | | $389.05 | $398.11 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $870.96 / $1,445.44
| Facility | | $676.08 | $870.96 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $2,570.40 / $2,570.40
| Professional | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $891.25
| Professional | | $851.14 | $851.14 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $1,000.00 / $1,023.29
| Facility | | $512.86 | $1,000.00 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $512.86 / $1,230.27
| Professional | | $354.81 | $512.86 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,570.88 / $4,570.88 / $4,570.88
| Facility | | $4,570.88 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,265.80 / $4,265.80 / $6,309.57
| Professional | | $4,265.80 | $4,265.80 | $6,309.57 |