- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $1,000.00
| Facility | | $758.58 | $758.58 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $724.44 / $1,071.52
| Professional | | $512.86 | $724.44 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $1,348.96
| Facility | | $758.58 | $758.58 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,621.81 / $1,995.26
| Professional | | $758.58 | $1,621.81 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,288.25 / $1,412.54
| Professional | | $1,096.48 | $1,288.25 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,548.82 / $6,309.57
| Facility | | $831.76 | $1,548.82 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $776.25 / $1,995.26
| Professional | | $575.44 | $776.25 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,380.38 / $1,819.70
| Professional | | $1,318.26 | $1,380.38 | $1,819.70 |
- 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
- $1,380.38 / $1,995.26 / $1,995.26
| Professional | | $1,380.38 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,737.80 / $2,630.27
| Professional | | $1,230.27 | $1,737.80 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $1,230.27 / $3,162.28
| Facility | | $467.74 | $1,230.27 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $602.56 / $1,148.15
| Professional | | $575.44 | $602.56 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,174.90 / $1,174.90
| Professional | | $933.25 | $1,174.90 | $1,174.90 |