- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $691.83 / $691.83
| Facility | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $691.83 / $1,148.15
| Professional | | $575.44 | $691.83 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,412.54 / $2,290.87
| Facility | | $1,412.54 | $1,412.54 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,318.26 / $1,584.89
| Professional | | $1,174.90 | $1,318.26 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $3,235.94 / $6,918.31
| Facility | | $812.83 | $3,235.94 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,995.26 / $2,630.27
| Professional | | $691.83 | $1,995.26 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,148.15 / $1,737.80
| Facility | | $691.83 | $1,148.15 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $2,290.87 / $2,884.03
| Professional | | $1,258.93 | $2,290.87 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,380.38 / $5,888.44
| Facility | | $691.83 | $1,380.38 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $912.01 / $1,621.81
| Professional | | $645.65 | $912.01 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $64.57 / $85.11
| Professional | | $54.95 | $64.57 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,584.89 / $2,754.23
| Professional | | $1,000.00 | $1,584.89 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $2,089.30 / $4,073.80
| Professional | | $1,412.54 | $2,089.30 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $2,818.38 / $6,165.95
| Facility | | $812.83 | $2,818.38 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,380.38 / $8,317.64
| Professional | | $691.83 | $1,380.38 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $977.24 / $1,412.54
| Facility | | $776.25 | $977.24 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $758.58 / $1,148.15
| Professional | | $549.54 | $758.58 | $1,148.15 |