- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $537.03 / $537.03
| Facility | | $537.03 | $537.03 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $537.03 / $3,801.89
| Professional | | $257.04 | $537.03 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $812.83 / $812.83
| Professional | | $741.31 | $812.83 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $933.25
| Facility | | $645.65 | $645.65 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $1,047.13 / $1,548.82
| Professional | | $645.65 | $1,047.13 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $912.01 / $4,265.80
| Facility | | $537.03 | $912.01 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $512.86 / $831.76
| Professional | | $275.42 | $512.86 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $2,238.72
| Professional | | $912.01 | $912.01 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $933.25 / $933.25
| Facility | | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $2,089.30 / $2,238.72
| Professional | | $1,148.15 | $2,089.30 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $602.56 / $933.25
| Facility | | $363.08 | $602.56 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $416.87 / $660.69
| Professional | | $302.00 | $416.87 | $660.69 |