- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $707.95 / $5,495.41
| Facility | | $165.96 | $707.95 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $371.54 / $707.95
| Professional | | $309.03 | $371.54 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $512.86 / $1,000.00
| Professional | | $363.08 | $512.86 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $1,513.56
| Facility | | $398.11 | $398.11 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $467.74 / $776.25
| Professional | | $346.74 | $467.74 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $537.03 / $831.76
| Professional | | $537.03 | $537.03 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $436.52 / $676.08
| Facility | | $331.13 | $436.52 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $575.44 / $776.25
| Professional | | $489.78 | $575.44 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $2,137.96 / $4,265.80
| Facility | | $912.01 | $2,137.96 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $371.54 / $691.83
| Professional | | $275.42 | $371.54 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,897.79 / $4,897.79 / $19,498.45
| Facility | | $4,897.79 | $4,897.79 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $2,691.53 / $3,235.94
| Professional | | $2,691.53 | $2,691.53 | $3,235.94 |