- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $645.65 / $4,073.80
| Professional | | $263.03 | $645.65 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $977.24 / $1,000.00
| Professional | | $891.25 | $977.24 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $512.86 / $1,148.15
| Facility | | $512.86 | $512.86 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $1,174.90 / $1,737.80
| Professional | | $512.86 | $1,174.90 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $1,122.02 / $3,981.07
| Facility | | $645.65 | $1,122.02 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $537.03 / $1,023.29
| Professional | | $338.84 | $537.03 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $2,754.23
| Professional | | $1,122.02 | $1,122.02 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $2,570.40 / $2,754.23
| Professional | | $1,412.54 | $2,570.40 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $630.96 / $954.99
| Facility | | $537.03 | $630.96 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $512.86 / $794.33
| Professional | | $371.54 | $512.86 | $794.33 |