- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $1,071.52 / $1,819.70
| Facility | | $371.54 | $1,071.52 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $229.09 / $1,584.89
| Professional | | $177.83 | $229.09 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $562.34 / $1,202.26
| Facility | | $138.04 | $562.34 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $389.05 / $794.33
| Professional | | $239.88 | $389.05 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $1,258.93 / $3,388.44
| Facility | | $85.11 | $1,258.93 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $239.88 / $602.56
| Professional | | $173.78 | $239.88 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $436.52 / $1,000.00
| Facility | | $204.17 | $436.52 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $199.53 / $691.83
| Professional | | $144.54 | $199.53 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $245.47 / $323.59
| Professional | | $213.80 | $245.47 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $269.15 / $426.58
| Professional | | $218.78 | $269.15 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,819.70 / $1,819.70
| Professional | | $1,202.26 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $239.88
| Professional | | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $288.40 / $724.44
| Facility | | $199.53 | $288.40 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $269.15 / $602.56
| Professional | | $144.54 | $269.15 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $851.14
| Professional | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $239.88 / $363.08
| Professional | | $194.98 | $239.88 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $239.88 / $239.88
| Facility | | $102.33 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $125.89 / $512.86
| Professional | | $102.33 | $125.89 | $512.86 |