- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $812.83 / $891.25
| Professional | | $549.54 | $812.83 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $2,290.87 / $2,290.87
| Facility | | $1,258.93 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,258.93 / $1,584.89
| Professional | | $691.83 | $1,258.93 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $6,165.95
| Facility | | $1,000.00 | $1,000.00 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,548.82 / $2,454.71
| Professional | | $851.14 | $1,548.82 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $691.83 / $1,380.38
| Facility | | $123.03 | $691.83 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $562.34 / $562.34
| Professional | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $812.83 / $6,456.54
| Facility | | $141.25 | $812.83 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $676.08 / $1,096.48
| Professional | | $467.74 | $676.08 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $72.44 / $107.15
| Professional | | $54.95 | $72.44 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $281.84 / $323.59
| Professional | | $141.25 | $281.84 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $2,290.87 / $6,760.83
| Facility | | $812.83 | $2,290.87 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $1,000.00 / $1,000.00
| Professional | | $100.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $363.08 / $812.83
| Facility | | $56.23 | $363.08 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $616.60 / $1,174.90
| Professional | | $457.09 | $616.60 | $1,174.90 |