- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $323.59 / $389.05
| Professional | | $199.53 | $323.59 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $489.78 / $1,548.82
| Professional | | $323.59 | $489.78 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $251.19 / $1,174.90
| Professional | | $245.47 | $251.19 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $588.84 / $2,691.53
| Facility | | $199.53 | $588.84 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $309.03 / $1,348.96
| Facility | | $199.53 | $309.03 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $616.60 / $2,089.30
| Professional | | $346.74 | $616.60 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $54.95 / $70.79
| Professional | | $50.12 | $54.95 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $741.31 / $1,071.52
| Professional | | $426.58 | $741.31 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $2,089.30 / $2,089.30
| Facility | | $741.31 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $2,089.30 / $2,089.30
| Professional | | $251.19 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $1,000.00 / $1,318.26
| Facility | | $288.40 | $1,000.00 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $501.19 / $1,230.27
| Professional | | $346.74 | $501.19 | $1,230.27 |