- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $724.44 / $4,786.30
| Facility | | $194.98 | $724.44 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $234.42 / $323.59
| Professional | | $190.55 | $234.42 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $1,122.02
| Facility | | $263.03 | $263.03 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $229.09
| Professional | | $128.82 | $128.82 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $707.95 / $1,445.44
| Professional | | $234.42 | $707.95 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $645.65 / $1,348.96
| Facility | | $263.03 | $645.65 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $177.83 / $537.03
| Professional | | $141.25 | $177.83 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $288.40 / $363.08
| Professional | | $263.03 | $288.40 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $371.54 / $524.81
| Facility | | $218.78 | $371.54 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $549.54
| Professional | | $144.54 | $144.54 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $354.81 / $10,000.00
| Facility | | $245.47 | $354.81 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $354.81 / $10,000.00
| Professional | | $245.47 | $354.81 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $263.03 / $426.58
| Facility | | $213.80 | $263.03 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $154.88 / $354.81
| Professional | | $109.65 | $154.88 | $354.81 |