- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $1,445.44 / $2,818.38
| Facility | | $575.44 | $1,445.44 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $575.44 / $758.58
| Professional | | $512.86 | $575.44 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $3,235.94
| Facility | | $758.58 | $758.58 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $302.00 / $562.34
| Professional | | $302.00 | $302.00 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $645.65 / $707.95
| Professional | | $588.84 | $645.65 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,862.09 / $3,890.45
| Facility | | $776.25 | $1,862.09 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $467.74 / $1,230.27
| Professional | | $371.54 | $467.74 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $831.76 / $1,071.52
| Professional | | $758.58 | $831.76 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $602.56 / $1,148.15
| Facility | | $457.09 | $602.56 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $1,584.89
| Professional | | $489.78 | $489.78 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $891.25 / $10,000.00
| Facility | | $575.44 | $891.25 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $891.25 / $10,000.00
| Professional | | $575.44 | $891.25 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $758.58 / $954.99
| Facility | | $316.23 | $758.58 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $398.11 / $812.83
| Professional | | $316.23 | $398.11 | $812.83 |