- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $794.33 / $1,412.54
| Facility | | $199.53 | $794.33 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $223.87 / $338.84
| Professional | | $100.00 | $223.87 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Professional | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $281.84 / $331.13
| Facility | | $251.19 | $281.84 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.96 / $281.84 / $281.84
| Professional | | $10.96 | $281.84 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $295.12 / $1,148.15
| Facility | | $199.53 | $295.12 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $229.09 / $512.86
| Professional | | $134.90 | $229.09 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $169.82 / $501.19
| Professional | | $91.20 | $169.82 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $223.87 / $371.54
| Professional | | $204.17 | $223.87 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $257.04 / $281.84
| Facility | | $117.49 | $257.04 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $117.49 / $371.54
| Professional | | $100.00 | $117.49 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $281.84 / $281.84
| Professional | | $204.17 | $281.84 | $281.84 |