- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $758.58 / $1,047.13
| Professional | | $457.09 | $758.58 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,288.25 / $1,819.70
| Facility | | $851.14 | $1,288.25 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,122.02 / $1,230.27
| Professional | | $1,071.52 | $1,122.02 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $724.44
| Facility | | $575.44 | $575.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $575.44 / $707.95
| Professional | | $489.78 | $575.44 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $562.34 / $1,047.13
| Facility | | $346.74 | $562.34 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $831.76 / $891.25
| Professional | | $776.25 | $831.76 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $741.31 / $758.58
| Professional | | $75.86 | $741.31 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,288.25 / $1,513.56
| Facility | | $851.14 | $1,288.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $630.96 / $660.69
| Professional | | $630.96 | $630.96 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $891.25 / $1,071.52
| Professional | | $870.96 | $891.25 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $389.05 / $616.60
| Facility | | $41.69 | $389.05 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $467.74 / $691.83
| Professional | | $436.52 | $467.74 | $691.83 |