- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $794.33 / $1,023.29
| Professional | | $512.86 | $794.33 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $186.21 / $186.21
| Professional | | $154.88 | $186.21 | $186.21 |
- 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
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $2,041.74 / $2,630.27
| Facility | | $1,659.59 | $2,041.74 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,905.46 / $2,630.27
| Professional | | $1,148.15 | $1,905.46 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $75.86 / $95.50
| Professional | | $60.26 | $75.86 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $91.20 / $1,819.70
| Facility | | $85.11 | $91.20 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $95.50 / $1,819.70
| Professional | | $87.10 | $95.50 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $112.20 / $10,000.00
| Facility | | $75.86 | $112.20 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $169.82 / $758.58
| Professional | | $75.86 | $169.82 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $186.21 / $186.21
| Professional | | $154.88 | $186.21 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $138.04 / $2,630.27
| Facility | | $77.62 | $138.04 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $123.03 / $724.44
| Professional | | $60.26 | $123.03 | $724.44 |