- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $724.44 / $1,905.46
| Facility | | $288.40 | $724.44 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $302.00 / $457.09
| Professional | | $104.71 | $302.00 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $1,621.81
| Facility | | $380.19 | $380.19 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $269.15
| Professional | | $151.36 | $151.36 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $1,445.44 / $3,019.95
| Professional | | $302.00 | $1,445.44 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $741.31 / $1,737.80
| Facility | | $263.03 | $741.31 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $229.09 / $389.05
| Professional | | $75.86 | $229.09 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $416.87 / $537.03
| Professional | | $380.19 | $416.87 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $457.09 / $1,174.90
| Facility | | $288.40 | $457.09 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $794.33 / $1,174.90
| Professional | | $245.47 | $794.33 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $457.09 / $10,000.00
| Facility | | $190.55 | $457.09 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $457.09 / $10,000.00
| Professional | | $190.55 | $457.09 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $380.19 / $457.09
| Facility | | $91.20 | $380.19 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $158.49 / $295.12
| Professional | | $63.10 | $158.49 | $295.12 |