- 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
- $478.63 / $870.96 / $1,047.13
| Professional | | $478.63 | $870.96 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $851.14 / $2,344.23
| Facility | | $85.11 | $851.14 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $707.95 / $1,047.13
| Professional | | $100.00 | $707.95 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $457.09 / $1,096.48
| Facility | | $457.09 | $457.09 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $389.05 / $467.74
| Professional | | $75.86 | $389.05 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $416.87 / $1,000.00
| Facility | | $91.20 | $416.87 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $870.96 / $1,047.13
| Professional | | $478.63 | $870.96 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $501.19 / $676.08
| Professional | | $51.29 | $501.19 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $707.95
| Professional | | $660.69 | $660.69 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $954.99 / $1,000.00
| Professional | | $758.58 | $954.99 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $524.81 / $741.31
| Facility | | $57.54 | $524.81 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $588.84 / $741.31
| Professional | | $467.74 | $588.84 | $741.31 |