- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $263.03 / $346.74
| Facility | | $223.87 | $263.03 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $309.03 / $389.05
| Professional | | $251.19 | $309.03 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $213.80 / $288.40
| Facility | | $204.17 | $213.80 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $363.08 / $407.38
| Professional | | $346.74 | $363.08 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $524.81 / $831.76
| Professional | | $354.81 | $524.81 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $478.63 / $691.83
| Facility | | $331.13 | $478.63 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $691.83 / $2,570.40
| Professional | | $363.08 | $691.83 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $588.84 / $1,000.00
| Professional | | $467.74 | $588.84 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $870.96 / $1,000.00
| Professional | | $537.03 | $870.96 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $851.14
| Professional | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.37 / $0.37 / $0.37
| Facility | | $0.37 | $0.37 | $0.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $562.34 / $812.83
| Professional | | $323.59 | $562.34 | $812.83 |