- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $549.54 / $812.83
| Professional | | $407.38 | $549.54 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $416.87
| Professional | | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,995.26 / $2,454.71
| Professional | | $691.83 | $1,995.26 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $691.83 / $1,000.00
| Facility | | $549.54 | $691.83 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $724.44 / $1,023.29
| Professional | | $676.08 | $724.44 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $891.25 / $1,148.15
| Facility | | $724.44 | $891.25 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $912.01 / $1,174.90
| Professional | | $812.83 | $912.01 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $776.25 / $1,202.26
| Facility | | $549.54 | $776.25 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $794.33 / $954.99
| Professional | | $79.43 | $794.33 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,445.44 / $3,548.13
| Facility | | $758.58 | $1,445.44 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,023.29 / $1,023.29
| Professional | | $912.01 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $467.74 / $1,479.11
| Facility | | $346.74 | $467.74 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $457.09 / $870.96
| Professional | | $354.81 | $457.09 | $870.96 |