- 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
- $281.84 / $588.84 / $5,128.61
| Professional | | $281.84 | $588.84 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $891.25 / $891.25
| Professional | | $812.83 | $891.25 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $1,023.29
| Facility | | $616.60 | $616.60 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $1,096.48 / $1,698.24
| Professional | | $616.60 | $1,096.48 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $1,023.29 / $4,677.35
| Facility | | $588.84 | $1,023.29 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $575.44 / $933.25
| Professional | | $309.03 | $575.44 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,023.29 / $2,454.71
| Professional | | $1,000.00 | $1,023.29 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,023.29 / $1,023.29
| Facility | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $2,290.87 / $2,454.71
| Professional | | $1,288.25 | $2,290.87 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $676.08 / $1,023.29
| Facility | | $575.44 | $676.08 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $457.09 / $724.44
| Professional | | $331.13 | $457.09 | $724.44 |