- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $602.56 / $1,258.93
| Facility | | $239.88 | $602.56 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $251.19 / $380.19
| Professional | | $208.93 | $251.19 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $1,348.96
| Facility | | $323.59 | $323.59 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $223.87
| Professional | | $128.82 | $128.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $269.15 / $302.00
| Professional | | $245.47 | $269.15 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $794.33 / $1,621.81
| Facility | | $323.59 | $794.33 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $194.98 / $524.81
| Professional | | $158.49 | $194.98 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $354.81 / $446.68
| Professional | | $323.59 | $354.81 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $354.81 / $549.54
| Facility | | $257.04 | $354.81 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $676.08
| Professional | | $208.93 | $208.93 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $457.09 / $10,000.00
| Facility | | $288.40 | $457.09 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $457.09 / $10,000.00
| Professional | | $288.40 | $457.09 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $323.59 / $380.19
| Facility | | $190.55 | $323.59 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $158.49 / $354.81
| Professional | | $134.90 | $158.49 | $354.81 |