- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $794.33 / $794.33
| Professional | | $501.19 | $794.33 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $2,187.76 / $2,187.76
| Facility | | $1,202.26 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,202.26 / $1,479.11
| Professional | | $912.01 | $1,202.26 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $4,786.30
| Facility | | $251.19 | $251.19 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $1,445.44 / $2,290.87
| Professional | | $213.80 | $1,445.44 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $380.19 / $794.33
| Facility | | $104.71 | $380.19 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $794.33 / $3,162.28
| Facility | | $104.71 | $794.33 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $602.56 / $933.25
| Professional | | $371.54 | $602.56 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.51 / $85.11 / $616.60
| Professional | | $1.51 | $85.11 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $954.99 / $1,000.00
| Professional | | $645.65 | $954.99 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $245.47 / $275.42
| Professional | | $134.90 | $245.47 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $1,258.93 / $3,890.45
| Facility | | $64.57 | $1,258.93 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $251.19 / $251.19
| Professional | | $89.13 | $251.19 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $371.54 / $616.60
| Facility | | $51.29 | $371.54 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $489.78 / $933.25
| Professional | | $331.13 | $489.78 | $933.25 |