- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $776.25 / $776.25
| Facility | | $776.25 | $776.25 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $776.25 / $1,148.15
| Professional | | $630.96 | $776.25 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $1,479.11 / $1,584.89
| Facility | | $1,479.11 | $1,479.11 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $1,698.24
| Professional | | $812.83 | $812.83 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $1,023.29
| Professional | | $812.83 | $812.83 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $977.24 / $977.24
| Facility | | $630.96 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $707.95
| Professional | | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,479.11 / $2,089.30
| Professional | | $1,122.02 | $1,479.11 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,096.48 / $1,096.48
| Professional | | $1,000.00 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,047.13 / $1,737.80
| Facility | | $630.96 | $1,047.13 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $891.25 / $977.24
| Professional | | $794.33 | $891.25 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,230.27 / $3,162.28
| Facility | | $831.76 | $1,230.27 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,230.27 / $3,162.28
| Professional | | $831.76 | $1,230.27 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $1,000.00 / $1,819.70
| Facility | | $512.86 | $1,000.00 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $724.44 / $1,174.90
| Professional | | $676.08 | $724.44 | $1,174.90 |