- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $691.83 / $691.83
| Facility | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $851.14 / $1,122.02
| Professional | | $575.44 | $851.14 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $204.17 / $204.17
| Professional | | $169.82 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $851.14 / $1,513.56
| Facility | | $223.87 | $851.14 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $724.44 / $851.14
| Professional | | $724.44 | $724.44 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $2,187.76 / $2,818.38
| Facility | | $1,737.80 | $2,187.76 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $2,041.74 / $2,818.38
| Professional | | $1,230.27 | $2,041.74 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $79.43 / $100.00
| Professional | | $60.26 | $79.43 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $1,584.89 / $1,905.46
| Facility | | $97.72 | $1,584.89 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $190.55 / $1,905.46
| Professional | | $97.72 | $190.55 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $120.23 / $10,000.00
| Facility | | $81.28 | $120.23 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $181.97 / $812.83
| Professional | | $81.28 | $181.97 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $204.17 / $204.17
| Professional | | $169.82 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $194.98 / $2,630.27
| Facility | | $72.44 | $194.98 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $117.49 / $776.25
| Professional | | $66.07 | $117.49 | $776.25 |