- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $851.14 / $1,023.29
| Professional | | $489.78 | $851.14 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $114.82 / $288.40
| Facility | | $89.13 | $114.82 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $933.25 / $3,235.94
| Professional | | $707.95 | $933.25 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $208.93 / $457.09
| Facility | | $95.50 | $208.93 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $67.61
| Facility | | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $4,073.80 / $5,128.61
| Professional | | $72.44 | $4,073.80 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $398.11 / $831.76
| Professional | | $128.82 | $398.11 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $338.84
| Professional | | $81.28 | $81.28 | $338.84 |
- 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
- $54.95 / $54.95 / $70.79
| Professional | | $54.95 | $54.95 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $245.47 / $1,000.00
| Facility | | $95.50 | $245.47 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $97.72 / $151.36
| Professional | | $70.79 | $97.72 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $87.10 / $2,187.76
| Facility | | $51.29 | $87.10 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $104.71 / $194.98
| Professional | | $51.29 | $104.71 | $194.98 |