- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $891.25 / $891.25
| Facility | | $724.44 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $758.58 / $891.25
| Professional | | $724.44 | $758.58 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $630.96
| Facility | | $575.44 | $575.44 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $831.76 / $1,047.13
| Professional | | $758.58 | $831.76 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $831.76 / $1,047.13
| Professional | | $275.42 | $831.76 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $891.25 / $1,348.96
| Facility | | $478.63 | $891.25 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,995.26 / $3,388.44
| Professional | | $1,202.26 | $1,995.26 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $1,202.26 / $1,230.27
| Professional | | $478.63 | $1,202.26 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $630.96 / $676.08
| Facility | | $575.44 | $630.96 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $1,202.26
| Professional | | $426.58 | $426.58 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $724.44 / $794.33
| Professional | | $691.83 | $724.44 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $1,995.26 / $3,311.31
| Facility | | $2.00 | $1,995.26 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $1,995.26 / $2,041.74
| Professional | | $1,995.26 | $1,995.26 | $2,041.74 |
- 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
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |