- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $794.33 / $1,023.29
| Professional | | $645.65 | $794.33 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $870.96 / $933.25
| Facility | | $870.96 | $870.96 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $741.31 / $870.96
| Professional | | $741.31 | $741.31 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,380.38 / $1,905.46
| Professional | | $1,202.26 | $1,380.38 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $1,047.13
| Professional | | $812.83 | $812.83 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $776.25 / $1,348.96
| Facility | | $446.68 | $776.25 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $158.49 / $1,258.93
| Facility | | $87.10 | $158.49 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $158.49 / $1,230.27
| Professional | | $87.10 | $158.49 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $467.74 / $891.25
| Facility | | $57.54 | $467.74 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $676.08 / $1,096.48
| Professional | | $630.96 | $676.08 | $1,096.48 |