- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $724.44 / $724.44
| Facility | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $724.44 / $6,606.93
| Professional | | $371.54 | $724.44 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,096.48 / $1,122.02
| Professional | | $1,000.00 | $1,096.48 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $1,288.25
| Facility | | $707.95 | $707.95 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $1,548.82 / $2,187.76
| Professional | | $707.95 | $1,548.82 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,288.25 / $6,025.60
| Facility | | $724.44 | $1,288.25 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $575.44 / $1,174.90
| Professional | | $380.19 | $575.44 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,258.93 / $3,090.30
| Professional | | $1,258.93 | $1,258.93 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $2,884.03 / $3,090.30
| Professional | | $1,584.89 | $2,884.03 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $676.08 / $1,318.26
| Facility | | $436.52 | $676.08 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $575.44 / $891.25
| Professional | | $416.87 | $575.44 | $891.25 |