- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $602.56 / $1,023.29
| Facility | | $173.78 | $602.56 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $190.55 / $323.59
| Professional | | $147.91 | $190.55 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $891.25 / $891.25
| Facility | | $575.44 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $194.98 / $331.13
| Professional | | $154.88 | $194.98 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $478.63 / $1,000.00
| Facility | | $177.83 | $478.63 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $151.36 / $389.05
| Professional | | $102.33 | $151.36 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $218.78 / $380.19
| Facility | | $173.78 | $218.78 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Professional | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $281.84 / $354.81
| Facility | | $177.83 | $281.84 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $131.83 / $251.19
| Professional | | $74.13 | $131.83 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,621.81
| Professional | | $1,122.02 | $1,122.02 | $1,621.81 |