- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $870.96 / $1,513.56
| Facility | | $707.95 | $870.96 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $794.33 / $1,445.44
| Professional | | $630.96 | $794.33 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,230.27 / $1,258.93
| Professional | | $1,230.27 | $1,230.27 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,584.89 / $1,698.24
| Professional | | $1,230.27 | $1,584.89 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $2,290.87
| Facility | | $912.01 | $912.01 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $912.01
| Professional | | $660.69 | $660.69 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $1,000.00 / $1,698.24
| Professional | | $371.54 | $1,000.00 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,318.26 / $1,348.96
| Professional | | $1,318.26 | $1,318.26 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $630.96 / $1,737.80
| Facility | | $489.78 | $630.96 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $794.33 / $954.99
| Professional | | $588.84 | $794.33 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $1,698.24
| Professional | | $758.58 | $758.58 | $1,698.24 |