- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $251.19 / $478.63
| Professional | | $186.21 | $251.19 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $562.34 / $2,344.23
| Facility | | $512.86 | $562.34 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $436.52 / $645.65
| Professional | | $223.87 | $436.52 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $758.58 / $1,000.00
| Facility | | $616.60 | $758.58 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $338.84 / $407.38
| Facility | | $281.84 | $338.84 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $338.84
| Professional | | $204.17 | $204.17 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $3,630.78 / $9,772.37
| Facility | | $60.26 | $3,630.78 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $512.86 / $758.58
| Professional | | $512.86 | $512.86 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $275.42
| Facility | | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $338.84
| Professional | | $275.42 | $275.42 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $562.34 / $2,344.23
| Facility | | $512.86 | $562.34 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $436.52 / $645.65
| Professional | | $223.87 | $436.52 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $512.86 / $512.86
| Professional | | $416.87 | $512.86 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $323.59 / $588.84
| Facility | | $120.23 | $323.59 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $346.74 / $512.86
| Professional | | $218.78 | $346.74 | $512.86 |