- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $588.84 / $1,513.56
| Facility | | $489.78 | $588.84 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $588.84 / $1,000.00
| Professional | | $489.78 | $588.84 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,202.26 / $1,288.25
| Facility | | $1,202.26 | $1,202.26 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $691.83 / $1,445.44
| Professional | | $691.83 | $691.83 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $630.96 / $831.76
| Professional | | $630.96 | $630.96 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $707.95 / $707.95
| Facility | | $575.44 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $524.81 / $707.95
| Professional | | $524.81 | $524.81 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,202.26 / $1,698.24
| Professional | | $912.01 | $1,202.26 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $794.33 / $1,202.26
| Professional | | $575.44 | $794.33 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $776.25 / $1,548.82
| Facility | | $489.78 | $776.25 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $776.25 / $1,513.56
| Professional | | $645.65 | $776.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,000.00 / $2,630.27
| Facility | | $691.83 | $1,000.00 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,000.00 / $2,630.27
| Professional | | $691.83 | $1,000.00 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $602.56 / $1,202.26
| Facility | | $389.05 | $602.56 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $588.84 / $977.24
| Professional | | $537.03 | $588.84 | $977.24 |