- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $870.96 / $1,148.15
| Facility | | $630.96 | $870.96 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $436.52 / $870.96
| Professional | | $416.87 | $436.52 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $436.52 / $645.65
| Facility | | $281.84 | $436.52 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $416.87 / $891.25
| Professional | | $257.04 | $416.87 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $501.19 / $707.95
| Facility | | $85.11 | $501.19 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $537.03 / $1,230.27
| Professional | | $416.87 | $537.03 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $446.68 / $588.84
| Facility | | $269.15 | $446.68 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $257.04
| Professional | | $257.04 | $257.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $416.87 / $831.76
| Professional | | $229.09 | $416.87 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $1,862.09 / $1,862.09
| Facility | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $467.74 / $645.65
| Facility | | $257.04 | $467.74 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $316.23
| Professional | | $257.04 | $257.04 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $645.65
| Professional | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $281.84 / $436.52
| Professional | | $204.17 | $281.84 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $1,288.25 / $1,288.25
| Facility | | $257.04 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $1,000.00
| Professional | | $416.87 | $416.87 | $1,000.00 |