- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $676.08 / $2,884.03
| Facility | | $123.03 | $676.08 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $575.44 / $794.33
| Professional | | $501.19 | $575.44 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $457.09 / $467.74
| Professional | | $380.19 | $457.09 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $758.58 / $891.25
| Facility | | $676.08 | $758.58 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.96 / $758.58 / $758.58
| Professional | | $10.96 | $758.58 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $691.83 / $3,090.30
| Facility | | $467.74 | $691.83 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $616.60 / $1,318.26
| Professional | | $380.19 | $616.60 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $457.09 / $1,318.26
| Professional | | $457.09 | $457.09 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $501.19 / $1,000.00
| Professional | | $457.09 | $501.19 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $478.63 / $758.58
| Facility | | $316.23 | $478.63 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $338.84 / $954.99
| Professional | | $281.84 | $338.84 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $457.09 / $758.58
| Professional | | $457.09 | $457.09 | $758.58 |