- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $1,380.38
| Facility | | $575.44 | $575.44 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $512.86 / $758.58
| Professional | | $389.05 | $512.86 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $870.96 / $870.96
| Facility | | $776.25 | $870.96 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $776.25 / $1,000.00
| Professional | | $776.25 | $776.25 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $588.84 / $588.84
| Facility | | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $588.84
| Professional | | $426.58 | $426.58 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $1,230.27 / $2,511.89
| Facility | | $549.54 | $1,230.27 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $1,122.02 / $1,995.26
| Professional | | $549.54 | $1,122.02 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $691.83 / $758.58
| Professional | | $75.86 | $691.83 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $870.96 / $891.25
| Facility | | $707.95 | $870.96 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $870.96 / $1,000.00
| Professional | | $870.96 | $870.96 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,318.26 / $1,778.28
| Facility | | $794.33 | $1,318.26 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $741.31 / $870.96
| Professional | | $741.31 | $741.31 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $870.96 / $870.96
| Facility | | $870.96 | $870.96 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $776.25 / $1,000.00
| Professional | | $776.25 | $776.25 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $1,174.90 / $1,412.54
| Facility | | $575.44 | $1,174.90 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $575.44 / $812.83
| Professional | | $407.38 | $575.44 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $776.25 / $1,380.38
| Professional | | $562.34 | $776.25 | $1,380.38 |