- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $1,819.70
| Facility | | $758.58 | $758.58 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $602.56 / $1,000.00
| Professional | | $436.52 | $602.56 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,096.48 / $1,096.48
| Facility | | $977.24 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $977.24 / $1,258.93
| Professional | | $977.24 | $977.24 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $457.09 / $630.96
| Professional | | $457.09 | $457.09 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,412.54 / $3,162.28
| Facility | | $630.96 | $1,412.54 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,318.26 / $2,344.23
| Professional | | $630.96 | $1,318.26 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $870.96 / $954.99
| Professional | | $75.86 | $870.96 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,096.48 / $1,122.02
| Facility | | $891.25 | $1,096.48 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,122.02 / $1,258.93
| Professional | | $1,023.29 | $1,122.02 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,659.59 / $2,290.87
| Facility | | $1,000.00 | $1,659.59 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $933.25 / $1,096.48
| Professional | | $933.25 | $933.25 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $977.24 / $1,258.93
| Professional | | $977.24 | $977.24 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $1,380.38 / $1,621.81
| Facility | | $501.19 | $1,380.38 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $537.03 / $954.99
| Professional | | $467.74 | $537.03 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $977.24 / $1,737.80
| Professional | | $389.05 | $977.24 | $1,737.80 |