- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $467.74 / $467.74
| Facility | | $363.08 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $309.03 / $467.74
| Professional | | $213.80 | $309.03 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $676.08
| Facility | | $346.74 | $346.74 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $616.60 / $776.25
| Professional | | $346.74 | $616.60 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $588.84 / $630.96
| Professional | | $501.19 | $588.84 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $758.58 / $2,570.40
| Facility | | $416.87 | $758.58 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $380.19 / $1,000.00
| Professional | | $281.84 | $380.19 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $691.83 / $776.25
| Professional | | $660.69 | $691.83 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $1,000.00 / $1,000.00
| Professional | | $575.44 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $616.60 / $1,318.26
| Facility | | $208.93 | $616.60 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $323.59 / $537.03
| Professional | | $275.42 | $323.59 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $588.84 / $588.84
| Professional | | $467.74 | $588.84 | $588.84 |