- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $977.24 / $977.24
| Facility | | $977.24 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $977.24 / $7,413.10
| Professional | | $478.63 | $977.24 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,479.11 / $1,479.11
| Professional | | $1,348.96 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $933.25 / $1,737.80
| Facility | | $933.25 | $933.25 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,905.46 / $2,818.38
| Professional | | $933.25 | $1,905.46 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,698.24 / $7,762.47
| Facility | | $977.24 | $1,698.24 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $933.25 / $1,584.89
| Professional | | $512.86 | $933.25 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $1,698.24 / $4,073.80
| Professional | | $1,698.24 | $1,698.24 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $3,801.89 / $4,073.80
| Professional | | $2,137.96 | $3,801.89 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $1,023.29 / $1,548.82
| Facility | | $426.58 | $1,023.29 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $758.58 / $1,202.26
| Professional | | $549.54 | $758.58 | $1,202.26 |