- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $616.60 / $1,047.13
| Facility | | $208.93 | $616.60 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $218.78 / $831.76
| Professional | | $138.04 | $218.78 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $281.84 / $1,174.90
| Facility | | $281.84 | $281.84 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $194.98
| Professional | | $112.20 | $112.20 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $309.03 / $630.96
| Professional | | $223.87 | $309.03 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.18 / $467.74 / $1,258.93
| Facility | | $13.18 | $467.74 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $173.78 / $457.09
| Professional | | $138.04 | $173.78 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $309.03 / $389.05
| Professional | | $281.84 | $309.03 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $309.03 / $478.63
| Facility | | $223.87 | $309.03 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $588.84
| Professional | | $104.71 | $104.71 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $371.54 / $10,000.00
| Facility | | $194.98 | $371.54 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $371.54 / $10,000.00
| Professional | | $194.98 | $371.54 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $281.84 / $331.13
| Facility | | $83.18 | $281.84 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $125.89 / $234.42
| Professional | | $72.44 | $125.89 | $234.42 |