- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Facility | | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $323.59 / $562.34
| Professional | | $251.19 | $323.59 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $524.81 / $1,000.00
| Facility | | $52.48 | $524.81 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $354.81 / $660.69
| Professional | | $58.88 | $354.81 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $467.74
| Facility | | $331.13 | $331.13 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $275.42 / $338.84
| Professional | | $38.02 | $275.42 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $234.42 / $416.87
| Facility | | $60.26 | $234.42 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $323.59 / $562.34
| Professional | | $251.19 | $323.59 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $309.03 / $416.87
| Professional | | $30.90 | $309.03 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $354.81
| Professional | | $338.84 | $338.84 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $489.78 / $588.84
| Professional | | $467.74 | $489.78 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $245.47 / $363.08
| Facility | | $25.12 | $245.47 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $281.84 / $436.52
| Professional | | $229.09 | $281.84 | $436.52 |