- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $1,584.89
| Facility | | $660.69 | $660.69 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $616.60 / $1,000.00
| Professional | | $457.09 | $616.60 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,000.00 / $1,000.00
| Facility | | $891.25 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $1,148.15
| Professional | | $891.25 | $891.25 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $660.69
| Facility | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $478.63 / $660.69
| Professional | | $478.63 | $478.63 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $1,445.44 / $2,951.21
| Facility | | $645.65 | $1,445.44 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $1,288.25 / $2,344.23
| Professional | | $645.65 | $1,288.25 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $776.25 / $851.14
| Professional | | $75.86 | $776.25 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,000.00 / $1,318.26
| Facility | | $812.83 | $1,000.00 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,023.29 / $1,348.96
| Professional | | $912.01 | $1,023.29 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,479.11 / $2,041.74
| Facility | | $891.25 | $1,479.11 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $1,000.00
| Professional | | $851.14 | $851.14 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $1,148.15
| Professional | | $891.25 | $891.25 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,380.38 / $1,659.59
| Facility | | $676.08 | $1,380.38 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $676.08 / $977.24
| Professional | | $478.63 | $676.08 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $891.25 / $1,548.82
| Professional | | $239.88 | $891.25 | $1,548.82 |