- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $724.44 / $1,445.44
| Facility | | $245.47 | $724.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $257.04 / $398.11
| Professional | | $218.78 | $257.04 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $1,412.54
| Facility | | $331.13 | $331.13 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $234.42
| Professional | | $131.83 | $131.83 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $724.44 / $1,479.11
| Professional | | $263.03 | $724.44 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $812.83 / $1,479.11
| Facility | | $338.84 | $812.83 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $199.53 / $512.86
| Professional | | $162.18 | $199.53 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $363.08 / $457.09
| Professional | | $331.13 | $363.08 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $380.19 / $562.34
| Facility | | $263.03 | $380.19 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $691.83
| Professional | | $213.80 | $213.80 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $389.05 / $10,000.00
| Facility | | $281.84 | $389.05 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $389.05 / $10,000.00
| Professional | | $281.84 | $389.05 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $331.13 / $398.11
| Facility | | $199.53 | $331.13 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $165.96 / $363.08
| Professional | | $138.04 | $165.96 | $363.08 |