- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $354.81 / $954.99
| Facility | | $194.98 | $354.81 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $213.80 / $426.58
| Professional | | $169.82 | $213.80 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,000.00 / $1,047.13
| Facility | | $891.25 | $1,000.00 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $162.18 / $281.84
| Professional | | $120.23 | $162.18 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $165.96 / $190.55
| Facility | | $25.70 | $165.96 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $870.96 / $1,348.96
| Facility | | $562.34 | $870.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $263.03 / $524.81
| Professional | | $169.82 | $263.03 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $562.34
| Facility | | $177.83 | $177.83 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $257.04 / $489.78
| Professional | | $165.96 | $257.04 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $489.78
| Facility | | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $281.84 / $467.74
| Professional | | $223.87 | $281.84 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $316.23 / $954.99
| Facility | | $302.00 | $316.23 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $218.78 / $380.19
| Professional | | $125.89 | $218.78 | $380.19 |