- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $794.33 / $1,000.00
| Professional | | $588.84 | $794.33 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $831.76 / $831.76
| Facility | | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $616.60
| Professional | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $2,951.21 / $3,630.78
| Professional | | $1,023.29 | $2,951.21 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,023.29 / $1,412.54
| Facility | | $812.83 | $1,023.29 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,071.52 / $1,513.56
| Professional | | $977.24 | $1,071.52 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,318.26 / $1,348.96
| Facility | | $1,071.52 | $1,318.26 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,348.96 / $1,479.11
| Professional | | $1,202.26 | $1,348.96 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,174.90 / $1,698.24
| Facility | | $776.25 | $1,174.90 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $1,174.90 / $1,412.54
| Professional | | $79.43 | $1,174.90 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $2,137.96 / $5,248.07
| Facility | | $1,122.02 | $2,137.96 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,513.56 / $1,513.56
| Professional | | $1,348.96 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $891.25 / $2,187.76
| Facility | | $616.60 | $891.25 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $676.08 / $1,288.25
| Professional | | $602.56 | $676.08 | $1,288.25 |