- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $1,584.89
| Facility | | $467.74 | $467.74 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $467.74 / $4,168.69
| Professional | | $234.42 | $467.74 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $707.95 / $707.95
| Professional | | $645.65 | $707.95 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $812.83
| Facility | | $446.68 | $446.68 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $1,000.00 / $1,412.54
| Professional | | $446.68 | $1,000.00 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $831.76 / $3,715.35
| Facility | | $467.74 | $831.76 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $446.68 / $776.25
| Professional | | $245.47 | $446.68 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $1,949.84
| Professional | | $794.33 | $794.33 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,819.70 / $1,949.84
| Professional | | $1,000.00 | $1,819.70 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $549.54 / $562.34
| Facility | | $331.13 | $549.54 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $363.08 / $575.44
| Professional | | $263.03 | $363.08 | $575.44 |