- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $954.99
| Facility | | $912.01 | $912.01 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $1,659.59
| Professional | | $912.01 | $912.01 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,348.96 / $2,344.23
| Professional | | $1,348.96 | $1,348.96 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $588.84 / $1,023.29
| Professional | | $588.84 | $588.84 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $239.88 / $316.23
| Facility | | $134.90 | $239.88 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $173.78 / $1,513.56
| Professional | | $120.23 | $173.78 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $954.99 / $1,659.59
| Facility | | $588.84 | $954.99 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $912.01 / $912.01
| Professional | | $109.65 | $912.01 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $562.34 / $1,000.00
| Facility | | $501.19 | $562.34 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $602.56 / $1,023.29
| Professional | | $467.74 | $602.56 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $1,513.56
| Facility | | $812.83 | $812.83 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $489.78
| Professional | | $125.89 | $125.89 | $489.78 |