- 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
- $707.95 / $1,023.29 / $1,288.25
| Professional | | $707.95 | $1,023.29 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $223.87 / $223.87
| Professional | | $181.97 | $223.87 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $954.99 / $1,949.84
| Facility | | $288.40 | $954.99 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $933.25
| Professional | | $794.33 | $794.33 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $2,818.38 / $3,548.13
| Facility | | $2,238.72 | $2,818.38 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $2,630.27 / $3,548.13
| Professional | | $1,548.82 | $2,630.27 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $125.89 / $128.82
| Professional | | $60.26 | $125.89 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $2,041.74 / $2,454.71
| Facility | | $125.89 | $2,041.74 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $269.15 / $2,454.71
| Professional | | $125.89 | $269.15 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $144.54 / $10,000.00
| Facility | | $104.71 | $144.54 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $223.87 / $1,047.13
| Professional | | $104.71 | $223.87 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $223.87 / $223.87
| Professional | | $181.97 | $223.87 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $208.93 / $3,388.44
| Facility | | $93.33 | $208.93 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $125.89 / $933.25
| Professional | | $77.62 | $125.89 | $933.25 |