- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $288.40 / $407.38
| Facility | | $204.17 | $288.40 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $181.97 / $407.38
| Professional | | $138.04 | $181.97 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $724.44
| Facility | | $208.93 | $208.93 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $120.23 / $354.81
| Professional | | $36.31 | $120.23 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $407.38 / $741.31
| Facility | | $398.11 | $407.38 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $208.93 / $489.78
| Professional | | $147.91 | $208.93 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $407.38 / $1,174.90
| Facility | | $199.53 | $407.38 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $199.53 / $363.08
| Professional | | $100.00 | $199.53 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $263.03 / $1,000.00
| Facility | | $177.83 | $263.03 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $169.82 / $1,047.13
| Professional | | $87.10 | $169.82 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $208.93 / $257.04
| Facility | | $104.71 | $208.93 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $125.89 / $281.84
| Professional | | $87.10 | $125.89 | $281.84 |