- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $257.04 / $812.83
| Facility | | $194.98 | $257.04 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $194.98 / $316.23
| Professional | | $177.83 | $194.98 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $1,000.00 / $1,000.00
| Facility | | $537.03 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $389.05
| Professional | | $109.65 | $109.65 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $524.81 / $1,096.48
| Facility | | $181.97 | $524.81 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $162.18 / $457.09
| Professional | | $112.20 | $162.18 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $245.47 / $426.58
| Facility | | $194.98 | $245.47 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Professional | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $257.04
| Professional | | $239.88 | $239.88 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $316.23 / $398.11
| Facility | | $199.53 | $316.23 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $165.96 / $363.08
| Professional | | $102.33 | $165.96 | $363.08 |
- 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 / $1,202.26 / $1,819.70
| Professional | | $1,202.26 | $1,202.26 | $1,819.70 |