- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $2,951.21
| Facility | | $363.08 | $363.08 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $371.54 / $2,570.40
| Professional | | $275.42 | $371.54 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $346.74 / $1,513.56
| Facility | | $275.42 | $346.74 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $371.54 / $977.24
| Professional | | $363.08 | $371.54 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $1,000.00 / $1,584.89
| Facility | | $407.38 | $1,000.00 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $1,258.93 / $2,570.40
| Professional | | $645.65 | $1,258.93 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $426.58 / $426.58
| Facility | | $316.23 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $426.58
| Professional | | $309.03 | $309.03 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $263.03 / $831.76
| Professional | | $208.93 | $263.03 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $616.60 / $1,071.52
| Professional | | $416.87 | $616.60 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $6,025.60 / $6,025.60
| Professional | | $4,073.80 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $812.83
| Professional | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $70.79
| Professional | | $54.95 | $54.95 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $616.60 / $870.96
| Facility | | $251.19 | $616.60 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $588.84
| Professional | | $309.03 | $309.03 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $1,288.25
| Professional | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $269.15 / $616.60
| Professional | | $208.93 | $269.15 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $398.11 / $812.83
| Facility | | $50.12 | $398.11 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $363.08 / $741.31
| Professional | | $281.84 | $363.08 | $741.31 |