- 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
- $436.52 / $602.56 / $1,000.00
| Professional | | $436.52 | $602.56 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $562.34 / $562.34
| Professional | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $2,238.72 / $2,691.53
| Professional | | $891.25 | $2,238.72 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $891.25 / $1,202.26
| Facility | | $724.44 | $891.25 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $954.99 / $1,288.25
| Professional | | $870.96 | $954.99 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,148.15 / $1,174.90
| Facility | | $954.99 | $1,148.15 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,202.26
| Professional | | $1,174.90 | $1,174.90 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $1,000.00 / $1,380.38
| Facility | | $602.56 | $1,000.00 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $1,023.29 / $1,258.93
| Professional | | $79.43 | $1,023.29 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,862.09 / $4,570.88
| Facility | | $977.24 | $1,862.09 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,318.26 / $1,318.26
| Professional | | $1,202.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $776.25 / $1,621.81
| Facility | | $389.05 | $776.25 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $501.19 / $954.99
| Professional | | $398.11 | $501.19 | $954.99 |