- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $199.53
| Facility | | $128.82 | $128.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $616.60 / $1,122.02
| Professional | | $128.82 | $616.60 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $954.99 / $4,073.80
| Professional | | $316.23 | $954.99 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $3,467.37
| Professional | | $128.82 | $128.82 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $190.55 / $616.60
| Facility | | $120.23 | $190.55 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $194.98 / $1,000.00
| Facility | | $128.82 | $194.98 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,737.80 / $3,630.78
| Professional | | $1,000.00 | $1,737.80 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $50.12 / $70.79
| Professional | | $32.36 | $50.12 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $398.11 / $1,905.46
| Professional | | $218.78 | $398.11 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $3,630.78 / $3,630.78
| Facility | | $389.05 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $3,630.78 / $3,630.78
| Professional | | $128.82 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,174.90
| Facility | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $1,445.44 / $3,548.13
| Professional | | $338.84 | $1,445.44 | $3,548.13 |