- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $478.63 / $478.63
| Facility | | $478.63 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $478.63 / $741.31
| Professional | | $338.84 | $478.63 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $588.84 / $588.84
| Facility | | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $426.58
| Professional | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $1,737.80 / $2,137.96
| Professional | | $602.56 | $1,737.80 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $602.56 / $831.76
| Facility | | $478.63 | $602.56 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $630.96 / $870.96
| Professional | | $575.44 | $630.96 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $776.25 / $1,023.29
| Facility | | $630.96 | $776.25 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $1,047.13
| Professional | | $794.33 | $794.33 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $676.08 / $1,000.00
| Facility | | $478.63 | $676.08 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $691.83 / $831.76
| Professional | | $79.43 | $691.83 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $1,258.93 / $3,090.30
| Facility | | $660.69 | $1,258.93 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $891.25 / $891.25
| Professional | | $794.33 | $891.25 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $588.84 / $1,288.25
| Facility | | $302.00 | $588.84 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $398.11 / $758.58
| Professional | | $309.03 | $398.11 | $758.58 |