- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $954.99 / $954.99
| Facility | | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $977.24 / $1,819.70
| Professional | | $851.14 | $977.24 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $1,905.46 / $3,162.28
| Facility | | $1,905.46 | $1,905.46 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $2,137.96
| Professional | | $1,778.28 | $1,778.28 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $4,466.84 / $9,549.93
| Facility | | $1,174.90 | $4,466.84 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $2,754.23 / $3,630.78
| Professional | | $851.14 | $2,754.23 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,548.82 / $2,398.83
| Facility | | $954.99 | $1,548.82 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,905.46 / $2,290.87
| Professional | | $1,071.52 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,905.46 / $10,000.00
| Facility | | $954.99 | $1,905.46 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,096.48 / $2,137.96
| Professional | | $870.96 | $1,096.48 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $1,258.93
| Professional | | $54.95 | $70.79 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $2,187.76 / $3,801.89
| Professional | | $1,348.96 | $2,187.76 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $2,951.21 / $5,888.44
| Professional | | $1,905.46 | $2,951.21 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $3,801.89 / $10,000.00
| Facility | | $1,174.90 | $3,801.89 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,737.80 / $12,589.25
| Professional | | $851.14 | $1,737.80 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,071.52 / $1,905.46
| Facility | | $724.44 | $1,071.52 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $933.25 / $1,659.59
| Professional | | $741.31 | $933.25 | $1,659.59 |