- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $851.14 / $2,089.30
| Facility | | $426.58 | $851.14 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $213.80 / $323.59
| Professional | | $112.20 | $213.80 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Facility | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $354.81 / $1,000.00
| Facility | | $162.18 | $354.81 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $1,071.52 / $1,071.52
| Professional | | $354.81 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,905.46 / $1,905.46
| Professional | | $1,202.26 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $263.03 / $630.96
| Facility | | $117.49 | $263.03 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $199.53 / $363.08
| Professional | | $102.33 | $199.53 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $251.19 / $407.38
| Facility | | $117.49 | $251.19 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $416.87 / $1,096.48
| Professional | | $218.78 | $416.87 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $83.18 / $186.21
| Facility | | $69.18 | $83.18 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $218.78 / $398.11
| Professional | | $177.83 | $218.78 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $134.90
| Professional | | $107.15 | $107.15 | $134.90 |