- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $870.96
| Facility | | $758.58 | $758.58 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $512.86 / $758.58
| Professional | | $371.54 | $512.86 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $1,096.48
| Facility | | $676.08 | $676.08 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,202.26 / $1,513.56
| Professional | | $676.08 | $1,202.26 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,258.93 / $1,513.56
| Professional | | $870.96 | $1,258.93 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,288.25 / $4,677.35
| Facility | | $676.08 | $1,288.25 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $660.69 / $1,659.59
| Professional | | $457.09 | $660.69 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,122.02 / $1,318.26
| Professional | | $1,071.52 | $1,122.02 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,659.59 / $1,659.59
| Professional | | $1,000.00 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $1,000.00 / $2,344.23
| Facility | | $436.52 | $1,000.00 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $524.81 / $933.25
| Professional | | $457.09 | $524.81 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $954.99 / $954.99
| Professional | | $758.58 | $954.99 | $954.99 |