- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $645.65 / $1,288.25
| Facility | | $218.78 | $645.65 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $218.78 / $354.81
| Professional | | $177.83 | $218.78 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $1,258.93
| Facility | | $295.12 | $295.12 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $208.93
| Professional | | $117.49 | $117.49 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $645.65 / $1,348.96
| Professional | | $234.42 | $645.65 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $724.44 / $1,348.96
| Facility | | $302.00 | $724.44 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $177.83 / $467.74
| Professional | | $144.54 | $177.83 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $323.59 / $416.87
| Professional | | $295.12 | $323.59 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $338.84 / $512.86
| Facility | | $234.42 | $338.84 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $616.60
| Professional | | $190.55 | $190.55 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $354.81 / $10,000.00
| Facility | | $251.19 | $354.81 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $354.81 / $10,000.00
| Professional | | $251.19 | $354.81 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $295.12 / $354.81
| Facility | | $177.83 | $295.12 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $147.91 / $323.59
| Professional | | $123.03 | $147.91 | $323.59 |