- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $891.25 / $1,071.52
| Professional | | $562.34 | $891.25 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $870.96 / $1,584.89
| Facility | | $87.10 | $870.96 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $724.44 / $1,202.26
| Professional | | $104.71 | $724.44 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $446.68
| Facility | | $426.58 | $426.58 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $363.08 / $426.58
| Professional | | $77.62 | $363.08 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $549.54 / $891.25
| Facility | | $114.82 | $549.54 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $891.25 / $1,071.52
| Professional | | $562.34 | $891.25 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $69.18 / $691.83
| Professional | | $51.29 | $69.18 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $691.83 / $724.44
| Professional | | $691.83 | $691.83 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,000.00 / $1,000.00
| Professional | | $724.44 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $331.13 / $758.58
| Facility | | $38.02 | $331.13 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $446.68 / $707.95
| Professional | | $380.19 | $446.68 | $707.95 |