- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $173.78 / $436.52
| Facility | | $95.50 | $173.78 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $281.84 / $1,000.00
| Professional | | $194.98 | $281.84 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $426.58
| Professional | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $1,584.89
| Facility | | $446.68 | $446.68 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $269.15 / $416.87
| Professional | | $257.04 | $269.15 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $446.68
| Professional | | $269.15 | $269.15 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $309.03
| Facility | | $295.12 | $295.12 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $295.12
| Professional | | $213.80 | $213.80 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $354.81 / $1,122.02
| Facility | | $229.09 | $354.81 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $218.78 / $2,818.38
| Professional | | $165.96 | $218.78 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $363.08 / $363.08
| Facility | | $199.53 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $218.78 / $338.84
| Professional | | $165.96 | $218.78 | $338.84 |