- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $707.95
| Facility | | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $691.83 / $977.24
| Professional | | $501.19 | $691.83 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $588.84 / $588.84
| Professional | | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $2,570.40 / $3,090.30
| Professional | | $891.25 | $2,570.40 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $870.96 / $1,230.27
| Facility | | $707.95 | $870.96 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $933.25 / $1,258.93
| Professional | | $851.14 | $933.25 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,122.02 / $1,202.26
| Facility | | $912.01 | $1,122.02 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $1,548.82
| Professional | | $1,148.15 | $1,148.15 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,000.00 / $1,584.89
| Facility | | $691.83 | $1,000.00 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $1,000.00 / $1,202.26
| Professional | | $79.43 | $1,000.00 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,819.70 / $4,570.88
| Facility | | $954.99 | $1,819.70 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,288.25 / $1,288.25
| Professional | | $1,174.90 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $870.96 / $1,862.09
| Facility | | $758.58 | $870.96 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $575.44 / $1,096.48
| Professional | | $446.68 | $575.44 | $1,096.48 |