- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $218.78 / $489.78
| Facility | | $208.93 | $218.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $489.78 / $2,511.89
| Professional | | $331.13 | $489.78 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $302.00 / $302.00
| Professional | | $302.00 | $302.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $616.60 / $630.96
| Professional | | $562.34 | $616.60 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $707.95 / $1,000.00
| Facility | | $630.96 | $707.95 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $933.25 / $1,819.70
| Professional | | $630.96 | $933.25 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $831.76 / $3,162.28
| Facility | | $489.78 | $831.76 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $537.03 / $851.14
| Professional | | $354.81 | $537.03 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,000.00 / $2,398.83
| Professional | | $977.24 | $1,000.00 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $2,238.72 / $2,398.83
| Professional | | $1,348.96 | $2,238.72 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $870.96 / $1,412.54
| Professional | | $660.69 | $870.96 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $575.44 / $812.83
| Facility | | $389.05 | $575.44 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $537.03 / $851.14
| Professional | | $346.74 | $537.03 | $851.14 |