- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $575.44
| Facility | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $575.44 / $794.33
| Professional | | $416.87 | $575.44 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $436.52 / $436.52
| Professional | | $436.52 | $436.52 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $2,089.30 / $2,570.40
| Professional | | $724.44 | $2,089.30 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $724.44 / $1,023.29
| Facility | | $575.44 | $724.44 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $776.25 / $1,071.52
| Professional | | $707.95 | $776.25 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $933.25 / $954.99
| Facility | | $758.58 | $933.25 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $954.99 / $1,174.90
| Professional | | $812.83 | $954.99 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $831.76 / $1,258.93
| Facility | | $575.44 | $831.76 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $831.76 / $1,000.00
| Professional | | $79.43 | $831.76 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,513.56 / $3,715.35
| Facility | | $794.33 | $1,513.56 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,071.52 / $1,071.52
| Professional | | $954.99 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $724.44 / $1,548.82
| Facility | | $478.63 | $724.44 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $478.63 / $912.01
| Professional | | $371.54 | $478.63 | $912.01 |