- 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
- $489.78 / $575.44 / $912.01
| Professional | | $489.78 | $575.44 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,174.90
| Facility | | $1,122.02 | $1,122.02 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $1,380.38
| Professional | | $660.69 | $660.69 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $588.84 / $758.58
| Professional | | $588.84 | $588.84 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $724.44 / $724.44
| Facility | | $467.74 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $524.81 / $724.44
| Professional | | $524.81 | $524.81 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,122.02 / $1,548.82
| Professional | | $831.76 | $1,122.02 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $724.44 / $1,096.48
| Professional | | $562.34 | $724.44 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $812.83 / $1,445.44
| Facility | | $478.63 | $812.83 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $645.65 / $724.44
| Professional | | $602.56 | $645.65 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $912.01 / $2,398.83
| Facility | | $630.96 | $912.01 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $912.01 / $2,398.83
| Professional | | $630.96 | $912.01 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $812.83 / $1,122.02
| Facility | | $416.87 | $812.83 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $549.54 / $870.96
| Professional | | $512.86 | $549.54 | $870.96 |