- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $5,495.41
| Facility | | $912.01 | $912.01 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $870.96 / $912.01
| Professional | | $794.33 | $870.96 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $1,479.11 / $2,511.89
| Facility | | $741.31 | $1,479.11 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $1,412.54
| Professional | | $851.14 | $851.14 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $851.14
| Professional | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,778.28 / $2,290.87
| Facility | | $954.99 | $1,778.28 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $912.01
| Professional | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $257.04 / $1,000.00
| Professional | | $181.97 | $257.04 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $1,071.52 / $1,548.82
| Facility | | $467.74 | $1,071.52 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,000.00 / $1,288.25
| Facility | | $831.76 | $1,000.00 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,000.00 / $1,288.25
| Professional | | $831.76 | $1,000.00 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $870.96 / $1,548.82
| Facility | | $707.95 | $870.96 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $1,071.52
| Professional | | $891.25 | $891.25 | $1,071.52 |