- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $870.96 / $870.96
| Facility | | $870.96 | $870.96 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $870.96 / $1,000.00
| Professional | | $549.54 | $870.96 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $1,621.81
| Facility | | $1,000.00 | $1,000.00 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $933.25 / $1,047.13
| Professional | | $741.31 | $933.25 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $2,951.21 / $4,897.79
| Facility | | $501.19 | $2,951.21 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $4,365.16 / $5,128.61
| Professional | | $776.25 | $4,365.16 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $467.74 / $1,174.90
| Facility | | $93.33 | $467.74 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $158.49
| Professional | | $79.43 | $79.43 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $512.86 / $2,187.76
| Facility | | $97.72 | $512.86 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $87.10 / $199.53
| Professional | | $46.77 | $87.10 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $64.57 / $89.13
| Professional | | $50.12 | $64.57 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $190.55 / $302.00
| Professional | | $100.00 | $190.55 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $1,047.13 / $1,548.82
| Facility | | $199.53 | $1,047.13 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $25.12 / $190.55
| Professional | | $25.12 | $25.12 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $87.10 / $2,089.30
| Facility | | $64.57 | $87.10 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $100.00 / $363.08
| Professional | | $53.70 | $100.00 | $363.08 |