- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $524.81 / $870.96
| Facility | | $194.98 | $524.81 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $165.96 / $616.60
| Professional | | $123.03 | $165.96 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,000.00 / $5,011.87
| Facility | | $758.58 | $1,000.00 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $338.84 / $707.95
| Facility | | $199.53 | $338.84 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $181.97 / $316.23
| Professional | | $97.72 | $181.97 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $186.21 / $281.84
| Professional | | $144.54 | $186.21 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $208.93
| Facility | | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $251.19 / $389.05
| Professional | | $154.88 | $251.19 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $398.11 / $707.95
| Facility | | $177.83 | $398.11 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $165.96 / $257.04
| Professional | | $123.03 | $165.96 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $229.09 / $630.96
| Facility | | $147.91 | $229.09 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $229.09 / $630.96
| Professional | | $147.91 | $229.09 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $208.93 / $251.19
| Facility | | $123.03 | $208.93 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $123.03 / $281.84
| Professional | | $87.10 | $123.03 | $281.84 |