- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $257.04
| Facility | | $257.04 | $257.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $257.04 / $1,737.80
| Professional | | $128.82 | $257.04 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $389.05 / $398.11
| Professional | | $354.81 | $389.05 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $457.09
| Facility | | $251.19 | $251.19 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $630.96 / $851.14
| Professional | | $199.53 | $630.96 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $446.68 / $2,089.30
| Facility | | $257.04 | $446.68 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $251.19 / $407.38
| Professional | | $134.90 | $251.19 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $1,096.48
| Professional | | $446.68 | $446.68 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $457.09 / $457.09
| Facility | | $457.09 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $1,000.00 / $1,096.48
| Professional | | $562.34 | $1,000.00 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $302.00 / $309.03
| Facility | | $181.97 | $302.00 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $199.53 / $316.23
| Professional | | $147.91 | $199.53 | $316.23 |