- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,778.28 / $3,311.31
| Facility | | $630.96 | $1,778.28 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $630.96 / $831.76
| Professional | | $416.87 | $630.96 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $831.76 / $3,548.13
| Facility | | $831.76 | $831.76 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $588.84
| Professional | | $338.84 | $338.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $707.95 / $794.33
| Professional | | $645.65 | $707.95 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $2,089.30 / $4,265.80
| Facility | | $851.14 | $2,089.30 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $524.81 / $1,380.38
| Professional | | $416.87 | $524.81 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $933.25 / $1,174.90
| Professional | | $831.76 | $933.25 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $630.96 / $1,148.15
| Facility | | $501.19 | $630.96 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $1,778.28
| Professional | | $263.03 | $263.03 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $1,023.29 / $10,000.00
| Facility | | $616.60 | $1,023.29 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $1,023.29 / $10,000.00
| Professional | | $616.60 | $1,023.29 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $831.76 / $1,000.00
| Facility | | $354.81 | $831.76 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $380.19 / $831.76
| Professional | | $245.47 | $380.19 | $831.76 |