- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $537.03 / $676.08
| Facility | | $537.03 | $537.03 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $501.19 / $741.31
| Professional | | $309.03 | $501.19 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $630.96 / $954.99
| Facility | | $630.96 | $630.96 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,122.02 / $1,412.54
| Professional | | $630.96 | $1,122.02 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $870.96 / $977.24
| Professional | | $741.31 | $870.96 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $1,000.00 / $4,073.80
| Facility | | $575.44 | $1,000.00 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $512.86 / $1,412.54
| Professional | | $380.19 | $512.86 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $977.24 / $1,148.15
| Professional | | $933.25 | $977.24 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $954.99 / $954.99
| Facility | | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,412.54 / $1,412.54
| Professional | | $870.96 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $870.96 / $1,995.26
| Facility | | $288.40 | $870.96 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $426.58 / $812.83
| Professional | | $371.54 | $426.58 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $812.83 / $812.83
| Professional | | $630.96 | $812.83 | $812.83 |