- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $2,511.89 / $2,511.89
| Facility | | $407.38 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $2,511.89 / $3,548.13
| Professional | | $676.08 | $2,511.89 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $741.31 / $912.01
| Professional | | $257.04 | $741.31 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $478.63 / $977.24
| Professional | | $281.84 | $478.63 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $2,511.89 / $8,912.51
| Facility | | $87.10 | $2,511.89 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $1,513.56 / $4,786.30
| Professional | | $275.42 | $1,513.56 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $707.95 / $7,585.78
| Professional | | $524.81 | $707.95 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $1,000.00 / $7,585.78
| Professional | | $524.81 | $1,000.00 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,981.07 / $6,918.31 / $8,912.51
| Facility | | $3,981.07 | $6,918.31 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $1,659.59 / $3,090.30
| Professional | | $295.12 | $1,659.59 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,623.41 / $5,623.41 / $6,606.93
| Professional | | $5,623.41 | $5,623.41 | $6,606.93 |