- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $588.84 / $1,258.93
| Facility | | $199.53 | $588.84 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $208.93 / $426.58
| Professional | | $169.82 | $208.93 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $1,122.02
| Facility | | $263.03 | $263.03 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $186.21
| Professional | | $104.71 | $104.71 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $588.84 / $1,258.93
| Professional | | $213.80 | $588.84 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $512.86 / $1,202.26
| Facility | | $309.03 | $512.86 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $162.18 / $398.11
| Professional | | $117.49 | $162.18 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $316.23 / $371.54
| Professional | | $263.03 | $316.23 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $346.74
| Professional | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $346.74 / $478.63
| Facility | | $239.88 | $346.74 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $549.54
| Professional | | $173.78 | $173.78 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $309.03 / $10,000.00
| Facility | | $223.87 | $309.03 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $316.23 / $10,000.00
| Professional | | $223.87 | $316.23 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $263.03 / $316.23
| Facility | | $147.91 | $263.03 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $245.47 / $436.52
| Professional | | $147.91 | $245.47 | $436.52 |