- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $707.95 / $707.95
| Facility | | $575.44 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $467.74 / $707.95
| Professional | | $338.84 | $467.74 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $1,000.00
| Facility | | $707.95 | $707.95 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $912.01 / $1,148.15
| Professional | | $707.95 | $912.01 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $870.96 / $912.01
| Professional | | $758.58 | $870.96 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $1,148.15 / $4,073.80
| Facility | | $616.60 | $1,148.15 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $588.84 / $1,513.56
| Professional | | $426.58 | $588.84 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,023.29 / $1,202.26
| Professional | | $977.24 | $1,023.29 | $1,202.26 |
- 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
- $912.01 / $1,513.56 / $1,513.56
| Professional | | $912.01 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $912.01 / $2,089.30
| Facility | | $389.05 | $912.01 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $478.63 / $812.83
| Professional | | $416.87 | $478.63 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $891.25 / $891.25
| Professional | | $691.83 | $891.25 | $891.25 |