- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $741.31 / $741.31
| Facility | | $660.69 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $1,023.29 / $1,380.38
| Professional | | $741.31 | $1,023.29 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $144.54 / $363.08
| Facility | | $114.82 | $144.54 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,258.93 / $4,677.35
| Professional | | $912.01 | $1,258.93 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $331.13 / $512.86
| Facility | | $104.71 | $331.13 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $2,137.96 / $2,951.21
| Professional | | $1,380.38 | $2,137.96 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,548.82
| Facility | | $1,122.02 | $1,122.02 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $954.99 / $1,445.44
| Professional | | $338.84 | $954.99 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $831.76 / $1,949.84
| Professional | | $398.11 | $831.76 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $10,000.00 / $10,000.00
| Facility | | $1,949.84 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $186.21 / $1,737.80
| Professional | | $186.21 | $186.21 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $1,023.29 / $2,344.23
| Facility | | $181.97 | $1,023.29 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $954.99 / $1,122.02
| Professional | | $338.84 | $954.99 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $602.56 / $1,096.48
| Facility | | $75.86 | $602.56 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $891.25 / $2,089.30
| Professional | | $707.95 | $891.25 | $2,089.30 |