- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $575.44
| Facility | | $549.54 | $549.54 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $2,691.53
| Professional | | $549.54 | $549.54 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,137.96 / $3,801.89
| Professional | | $2,137.96 | $2,137.96 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $4,365.16
| Professional | | $1,000.00 | $1,000.00 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $251.19 / $316.23
| Facility | | $177.83 | $251.19 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $173.78 / $2,398.83
| Professional | | $120.23 | $173.78 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $588.84 / $1,995.26
| Facility | | $549.54 | $588.84 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $549.54 / $1,000.00
| Professional | | $109.65 | $549.54 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $173.78 / $1,862.09
| Facility | | $131.83 | $173.78 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $173.78 / $1,862.09
| Professional | | $131.83 | $173.78 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,454.71 / $4,570.88 / $6,025.60
| Facility | | $2,454.71 | $4,570.88 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $2,818.38
| Professional | | $125.89 | $125.89 | $2,818.38 |