- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $3,801.89 / $12,589.25
| Facility | | $776.25 | $3,801.89 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $389.05 / $1,778.28
| Professional | | $302.00 | $389.05 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $3,019.95 / $5,888.44
| Facility | | $2,290.87 | $3,019.95 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $489.78 / $676.08
| Professional | | $288.40 | $489.78 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $758.58 / $1,047.13
| Professional | | $354.81 | $758.58 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $512.86 / $1,479.11
| Facility | | $302.00 | $512.86 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $616.60 / $2,630.27
| Professional | | $363.08 | $616.60 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $758.58 / $954.99
| Professional | | $676.08 | $758.58 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $776.25 / $1,071.52
| Professional | | $602.56 | $776.25 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $1,047.13 / $3,801.89
| Facility | | $309.03 | $1,047.13 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $512.86 / $812.83
| Professional | | $346.74 | $512.86 | $812.83 |