- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $776.25 / $776.25
| Facility | | $776.25 | $776.25 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $776.25 / $1,122.02
| Professional | | $501.19 | $776.25 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,258.93 / $1,621.81
| Facility | | $912.01 | $1,258.93 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,023.29 / $1,071.52
| Professional | | $1,023.29 | $1,023.29 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $645.65
| Facility | | $616.60 | $616.60 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $616.60 / $707.95
| Professional | | $524.81 | $616.60 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $691.83 / $977.24
| Facility | | $97.72 | $691.83 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $977.24 / $1,023.29
| Professional | | $912.01 | $977.24 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $707.95 / $724.44
| Professional | | $72.44 | $707.95 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,479.11 / $1,621.81
| Facility | | $977.24 | $1,479.11 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $741.31
| Professional | | $707.95 | $707.95 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,023.29 / $1,023.29
| Professional | | $758.58 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $338.84 / $660.69
| Facility | | $33.88 | $338.84 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $426.58 / $676.08
| Professional | | $389.05 | $426.58 | $676.08 |