- 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
- $537.03 / $870.96 / $1,000.00
| Professional | | $537.03 | $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
- $107.15 / $776.25 / $1,288.25
| Facility | | $107.15 | $776.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $758.58 / $1,819.70
| Professional | | $97.72 | $758.58 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $2,951.21 / $4,897.79
| Facility | | $891.25 | $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 / $660.69 / $1,230.27
| Facility | | $93.33 | $660.69 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $616.60 / $831.76
| Professional | | $158.49 | $616.60 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $870.96 / $4,786.30
| Facility | | $97.72 | $870.96 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $107.15 / $4,677.35
| Professional | | $51.29 | $107.15 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $64.57 / $89.13
| Professional | | $54.95 | $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
- $707.95 / $4,786.30 / $5,011.87
| Facility | | $707.95 | $4,786.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $3,801.89 / $4,677.35
| Professional | | $758.58 | $3,801.89 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $104.71 / $1,862.09
| Facility | | $77.62 | $104.71 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $107.15 / $870.96
| Professional | | $54.95 | $107.15 | $870.96 |