- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $457.09 / $457.09
| Facility | | $457.09 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $489.78
| Professional | | $446.68 | $446.68 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,445.44 / $2,754.23
| Professional | | $891.25 | $1,445.44 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $1,000.00 / $1,737.80
| Facility | | $199.53 | $1,000.00 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $223.87 / $616.60
| Professional | | $125.89 | $223.87 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $467.74 / $1,000.00
| Facility | | $446.68 | $467.74 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $676.08
| Professional | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $501.19 / $1,380.38
| Facility | | $478.63 | $501.19 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $478.63 / $1,548.82
| Professional | | $478.63 | $478.63 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $85.11 / $446.68
| Professional | | $58.88 | $85.11 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $302.00 / $1,819.70
| Professional | | $141.25 | $302.00 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $1,174.90 / $2,691.53
| Facility | | $446.68 | $1,174.90 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $512.86 / $2,691.53
| Professional | | $446.68 | $512.86 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $602.56 / $741.31
| Professional | | $602.56 | $602.56 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $478.63 / $1,122.02
| Facility | | $478.63 | $478.63 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $478.63
| Professional | | $125.89 | $125.89 | $478.63 |