- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $3,801.89 / $12,589.25
| Facility | | $741.31 | $3,801.89 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $407.38 / $1,174.90
| Professional | | $190.55 | $407.38 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $691.83
| Professional | | $416.87 | $416.87 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,174.90 / $2,290.87
| Facility | | $891.25 | $1,174.90 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $398.11 / $676.08
| Professional | | $245.47 | $398.11 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $676.08 / $1,071.52
| Professional | | $426.58 | $676.08 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $489.78 / $1,513.56
| Facility | | $275.42 | $489.78 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $691.83 / $2,691.53
| Professional | | $398.11 | $691.83 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $676.08 / $1,000.00
| Professional | | $467.74 | $676.08 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $660.69 / $794.33
| Professional | | $478.63 | $660.69 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $1,047.13 / $3,801.89
| Facility | | $501.19 | $1,047.13 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $489.78 / $851.14
| Professional | | $288.40 | $489.78 | $851.14 |