- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $691.83 / $691.83
| Facility | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $812.83 / $1,148.15
| Professional | | $660.69 | $812.83 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,548.82 / $1,819.70
| Professional | | $891.25 | $1,548.82 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $912.01 / $1,000.00
| Facility | | $676.08 | $912.01 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $2,089.30
| Professional | | $660.69 | $660.69 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $870.96 / $912.01
| Professional | | $870.96 | $870.96 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,230.27 / $2,454.71
| Facility | | $691.83 | $1,230.27 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $478.63
| Professional | | $467.74 | $467.74 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $1,047.13
| Professional | | $30.20 | $30.20 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,096.48 / $1,995.26
| Facility | | $954.99 | $1,096.48 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $758.58 / $1,096.48
| Professional | | $602.56 | $758.58 | $1,096.48 |