- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $891.25 / $891.25
| Facility | | $549.54 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $794.33 / $1,000.00
| Professional | | $512.86 | $794.33 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $724.44 / $1,096.48
| Professional | | $724.44 | $724.44 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $3,090.30 / $3,090.30
| Professional | | $85.11 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $1,000.00 / $1,412.54
| Facility | | $213.80 | $1,000.00 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $776.25 / $776.25
| Professional | | $776.25 | $776.25 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,071.52 / $1,288.25
| Professional | | $812.83 | $1,071.52 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $812.83 / $1,445.44
| Facility | | $117.49 | $812.83 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $125.89 / $125.89
| Professional | | $58.88 | $125.89 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $181.97 / $1,995.26
| Facility | | $75.86 | $181.97 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $186.21 / $1,995.26
| Professional | | $75.86 | $186.21 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $104.71 / $1,380.38
| Facility | | $77.62 | $104.71 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $109.65 / $537.03
| Professional | | $60.26 | $109.65 | $537.03 |