- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,737.80 / $2,137.96
| Facility | | $758.58 | $1,737.80 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $794.33 / $1,621.81
| Professional | | $758.58 | $794.33 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,479.11 / $2,511.89
| Facility | | $724.44 | $1,479.11 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $724.44 / $1,230.27
| Professional | | $724.44 | $724.44 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,230.27 / $1,862.09
| Professional | | $1,071.52 | $1,230.27 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,380.38 / $1,819.70
| Facility | | $1,023.29 | $1,380.38 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $724.44 / $724.44
| Professional | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $758.58 / $1,202.26
| Professional | | $616.60 | $758.58 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,000.00 / $1,698.24
| Facility | | $758.58 | $1,000.00 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,023.29 / $1,071.52
| Facility | | $691.83 | $1,023.29 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,023.29 / $1,071.52
| Professional | | $691.83 | $1,023.29 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $977.24 / $1,698.24
| Facility | | $724.44 | $977.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $758.58 / $977.24
| Professional | | $741.31 | $758.58 | $977.24 |