- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $660.69
| Facility | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $660.69 / $6,025.60
| Professional | | $338.84 | $660.69 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,000.00 / $1,023.29
| Professional | | $912.01 | $1,000.00 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $776.25 / $1,174.90
| Facility | | $776.25 | $776.25 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,445.44 / $1,995.26
| Professional | | $776.25 | $1,445.44 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $1,174.90 / $5,623.41
| Facility | | $660.69 | $1,174.90 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $524.81 / $1,071.52
| Professional | | $346.74 | $524.81 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $2,818.38
| Professional | | $1,148.15 | $1,148.15 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,174.90
| Facility | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $2,630.27 / $2,818.38
| Professional | | $1,445.44 | $2,630.27 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $616.60 / $1,202.26
| Facility | | $398.11 | $616.60 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $524.81 / $794.33
| Professional | | $380.19 | $524.81 | $794.33 |