- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $363.08 / $575.44
| Facility | | $194.98 | $363.08 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $177.83 / $380.19
| Professional | | $112.20 | $177.83 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $537.03
| Facility | | $208.93 | $208.93 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $398.11
| Professional | | $83.18 | $83.18 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $208.93 / $208.93
| Facility | | $123.03 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $208.93 / $208.93
| Professional | | $151.36 | $208.93 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $446.68 / $537.03
| Facility | | $204.17 | $446.68 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $263.03 / $1,000.00
| Professional | | $128.82 | $263.03 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $269.15 / $575.44
| Facility | | $173.78 | $269.15 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $186.21 / $389.05
| Professional | | $144.54 | $186.21 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Facility | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $194.98 / $398.11
| Professional | | $125.89 | $194.98 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $389.05 / $50,118.72
| Facility | | $208.93 | $389.05 | $50,118.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $213.80
| Professional | | $208.93 | $208.93 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $208.93 / $257.04
| Facility | | $186.21 | $208.93 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $173.78 / $416.87
| Professional | | $87.10 | $173.78 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $151.36 / $245.47
| Facility | | $125.89 | $151.36 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $199.53 / $398.11
| Professional | | $125.89 | $199.53 | $398.11 |