- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $1,288.25 / $1,862.09
| Facility | | $524.81 | $1,288.25 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $575.44 / $812.83
| Professional | | $204.17 | $575.44 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $1,584.89
| Facility | | $812.83 | $812.83 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,288.25 / $1,621.81
| Professional | | $812.83 | $1,288.25 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $954.99 / $1,174.90
| Professional | | $575.44 | $954.99 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $812.83 / $1,737.80
| Facility | | $645.65 | $812.83 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $288.40 / $2,570.40
| Professional | | $169.82 | $288.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $870.96
| Professional | | $812.83 | $812.83 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $724.44 / $1,445.44
| Professional | | $676.08 | $724.44 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $1,548.82
| Facility | | $676.08 | $676.08 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $776.25
| Professional | | $169.82 | $169.82 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $676.08
| Professional | | $676.08 | $676.08 | $676.08 |