- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $870.96 / $1,000.00
| Facility | | $812.83 | $870.96 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $977.24 / $1,412.54
| Professional | | $812.83 | $977.24 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $1,445.44
| Professional | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,819.70 / $1,949.84
| Professional | | $1,412.54 | $1,819.70 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,318.26 / $3,019.95
| Facility | | $1,318.26 | $1,318.26 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $977.24 / $1,318.26
| Professional | | $977.24 | $977.24 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $1,148.15 / $1,949.84
| Professional | | $426.58 | $1,148.15 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,513.56 / $1,548.82
| Professional | | $1,513.56 | $1,513.56 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,258.93 / $2,290.87
| Facility | | $758.58 | $1,258.93 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $933.25 / $1,258.93
| Professional | | $831.76 | $933.25 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,023.29 / $1,949.84
| Professional | | $1,023.29 | $1,023.29 | $1,949.84 |