- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $776.25 / $776.25
| Facility | | $776.25 | $776.25 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $776.25 / $6,606.93
| Professional | | $363.08 | $776.25 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,174.90 / $1,174.90
| Professional | | $1,071.52 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $1,348.96
| Facility | | $707.95 | $707.95 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $1,513.56 / $2,187.76
| Professional | | $707.95 | $1,513.56 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,348.96 / $6,025.60
| Facility | | $776.25 | $1,348.96 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $602.56 / $1,230.27
| Professional | | $407.38 | $602.56 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,348.96 / $3,235.94
| Professional | | $1,318.26 | $1,348.96 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,348.96 / $1,348.96
| Facility | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $3,019.95 / $3,235.94
| Professional | | $1,698.24 | $3,019.95 | $3,235.94 |
- 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
- $436.52 / $602.56 / $954.99
| Professional | | $436.52 | $602.56 | $954.99 |