- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $562.34 / $1,479.11
| Professional | | $281.84 | $562.34 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $724.44 / $741.31
| Professional | | $660.69 | $724.44 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $1,122.02
| Facility | | $758.58 | $758.58 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,096.48 / $2,089.30
| Professional | | $758.58 | $1,096.48 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $1,000.00 / $3,388.44
| Facility | | $562.34 | $1,000.00 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $616.60 / $954.99
| Professional | | $407.38 | $616.60 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,122.02 / $2,691.53
| Professional | | $1,096.48 | $1,122.02 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,122.02
| Facility | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $2,511.89 / $2,691.53
| Professional | | $1,513.56 | $2,511.89 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $660.69 / $1,047.13
| Facility | | $436.52 | $660.69 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $616.60 / $954.99
| Professional | | $389.05 | $616.60 | $954.99 |