- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $812.83 / $954.99
| Facility | | $478.63 | $812.83 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $426.58 / $954.99
| Professional | | $323.59 | $426.58 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $1,698.24
| Facility | | $489.78 | $489.78 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $467.74 / $1,174.90
| Professional | | $239.88 | $467.74 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,000.00 / $1,096.48
| Facility | | $933.25 | $1,000.00 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $489.78 / $1,148.15
| Professional | | $338.84 | $489.78 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $954.99 / $2,754.23
| Facility | | $645.65 | $954.99 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $426.58 / $1,819.70
| Professional | | $239.88 | $426.58 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $758.58 / $2,344.23
| Facility | | $426.58 | $758.58 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $407.38 / $3,981.07
| Professional | | $204.17 | $407.38 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $588.84 / $676.08
| Facility | | $177.83 | $588.84 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $295.12 / $676.08
| Professional | | $204.17 | $295.12 | $676.08 |