- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $776.25 / $1,380.38
| Facility | | $691.83 | $776.25 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $691.83 / $1,000.00
| Professional | | $691.83 | $691.83 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $691.83 / $870.96
| Professional | | $691.83 | $691.83 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $691.83 / $1,258.93
| Professional | | $588.84 | $691.83 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $724.44 / $1,174.90
| Facility | | $691.83 | $724.44 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $758.58 / $2,818.38
| Professional | | $691.83 | $758.58 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $831.76 / $1,023.29
| Professional | | $776.25 | $831.76 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $776.25 / $831.76
| Professional | | $776.25 | $776.25 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $1,230.27 / $1,445.44
| Professional | | $741.31 | $1,230.27 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $691.83 / $776.25
| Facility | | $691.83 | $691.83 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $691.83 / $794.33
| Professional | | $645.65 | $691.83 | $794.33 |
- 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
- $588.84 / $758.58 / $758.58
| Professional | | $588.84 | $758.58 | $758.58 |