- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $616.60 / $812.83
| Professional | | $426.58 | $616.60 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $616.60
| Facility | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $446.68
| Professional | | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $2,187.76 / $2,630.27
| Professional | | $831.76 | $2,187.76 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $812.83 / $1,096.48
| Facility | | $645.65 | $812.83 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,000.00 / $1,202.26
| Professional | | $812.83 | $1,000.00 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,071.52 / $1,096.48
| Facility | | $1,047.13 | $1,071.52 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,071.52
| Professional | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $933.25 / $1,202.26
| Facility | | $630.96 | $933.25 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $933.25 / $1,148.15
| Professional | | $79.43 | $933.25 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,698.24 / $4,265.80
| Facility | | $891.25 | $1,698.24 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,202.26 / $1,202.26
| Professional | | $1,096.48 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $549.54 / $1,621.81
| Facility | | $389.05 | $549.54 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $489.78 / $933.25
| Professional | | $436.52 | $489.78 | $933.25 |