- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $977.24 / $1,288.25
| Facility | | $389.05 | $977.24 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $416.87 / $616.60
| Professional | | $338.84 | $416.87 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $512.86 / $2,187.76
| Facility | | $512.86 | $512.86 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $346.74
| Professional | | $208.93 | $208.93 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $1,122.02 / $2,344.23
| Professional | | $416.87 | $1,122.02 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $1,000.00 / $2,630.27
| Facility | | $524.81 | $1,000.00 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $323.59 / $831.76
| Professional | | $257.04 | $323.59 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $575.44 / $724.44
| Professional | | $512.86 | $575.44 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $512.86 / $891.25
| Facility | | $389.05 | $512.86 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $1,096.48
| Professional | | $338.84 | $338.84 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $602.56 / $10,000.00
| Facility | | $446.68 | $602.56 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $616.60 / $10,000.00
| Professional | | $446.68 | $616.60 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $512.86 / $616.60
| Facility | | $309.03 | $512.86 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $257.04 / $575.44
| Professional | | $218.78 | $257.04 | $575.44 |