- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $851.14 / $1,288.25
| Facility | | $398.11 | $851.14 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $218.78 / $316.23
| Professional | | $169.82 | $218.78 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Facility | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $562.34 / $1,000.00
| Facility | | $309.03 | $562.34 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $234.42 / $363.08
| Professional | | $208.93 | $234.42 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,698.24 / $1,698.24
| Professional | | $1,288.25 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $407.38 / $794.33
| Facility | | $218.78 | $407.38 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $218.78 / $363.08
| Professional | | $169.82 | $218.78 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $380.19 / $691.83
| Facility | | $218.78 | $380.19 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $234.42 / $363.08
| Professional | | $208.93 | $234.42 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $371.54 / $851.14
| Facility | | $281.84 | $371.54 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $380.19 / $660.69
| Professional | | $309.03 | $380.19 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $194.98 / $229.09
| Professional | | $186.21 | $194.98 | $229.09 |