- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $1,230.27 / $1,584.89
| Facility | | $478.63 | $1,230.27 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $478.63 / $776.25
| Professional | | $416.87 | $478.63 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $2,754.23
| Facility | | $645.65 | $645.65 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $426.58
| Professional | | $257.04 | $257.04 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $537.03 / $602.56
| Professional | | $489.78 | $537.03 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $1,258.93 / $3,311.31
| Facility | | $660.69 | $1,258.93 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $398.11 / $1,023.29
| Professional | | $316.23 | $398.11 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $707.95 / $891.25
| Professional | | $645.65 | $707.95 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $645.65 / $1,096.48
| Facility | | $478.63 | $645.65 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $1,348.96
| Professional | | $416.87 | $416.87 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $758.58 / $10,000.00
| Facility | | $549.54 | $758.58 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $776.25 / $10,000.00
| Professional | | $549.54 | $776.25 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $645.65 / $776.25
| Facility | | $389.05 | $645.65 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $323.59 / $707.95
| Professional | | $269.15 | $323.59 | $707.95 |