- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $851.14
| Facility | | $575.44 | $575.44 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $575.44 / $812.83
| Professional | | $407.38 | $575.44 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $562.34 / $1,023.29
| Facility | | $562.34 | $562.34 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $1,348.96 / $1,698.24
| Professional | | $562.34 | $1,348.96 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $933.25 / $1,174.90
| Professional | | $870.96 | $933.25 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $1,174.90 / $4,897.79
| Facility | | $616.60 | $1,174.90 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $575.44 / $1,513.56
| Professional | | $436.52 | $575.44 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,047.13 / $1,380.38
| Professional | | $1,000.00 | $1,047.13 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,023.29 / $1,023.29
| Facility | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,513.56 / $1,513.56
| Professional | | $1,047.13 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $933.25 / $2,398.83
| Facility | | $338.84 | $933.25 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $457.09 / $977.24
| Professional | | $426.58 | $457.09 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $891.25 / $891.25
| Professional | | $707.95 | $891.25 | $891.25 |