- 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
- $741.31 / $870.96 / $1,348.96
| Professional | | $741.31 | $870.96 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $1,698.24 / $1,778.28
| Facility | | $1,698.24 | $1,698.24 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $2,089.30
| Professional | | $1,000.00 | $1,000.00 | $2,089.30 |
- 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
- $870.96 / $1,318.26 / $1,318.26
| Facility | | $870.96 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $977.24 / $1,096.48
| Professional | | $977.24 | $977.24 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,698.24 / $2,344.23
| Professional | | $1,258.93 | $1,698.24 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,096.48 / $1,659.59
| Professional | | $912.01 | $1,096.48 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,202.26 / $2,041.74
| Facility | | $724.44 | $1,202.26 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,000.00 / $1,096.48
| Professional | | $912.01 | $1,000.00 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,380.38 / $3,630.78
| Facility | | $954.99 | $1,380.38 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,380.38 / $3,630.78
| Professional | | $954.99 | $1,380.38 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,230.27 / $1,698.24
| Facility | | $630.96 | $1,230.27 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $851.14 / $1,318.26
| Professional | | $776.25 | $851.14 | $1,318.26 |