- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $776.25 / $1,230.27
| Facility | | $251.19 | $776.25 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $239.88 / $891.25
| Professional | | $194.98 | $239.88 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,949.84 / $5,011.87
| Facility | | $1,445.44 | $1,949.84 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $229.09
| Professional | | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $478.63 / $1,000.00
| Facility | | $288.40 | $478.63 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $316.23 / $660.69
| Professional | | $173.78 | $316.23 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $263.03 / $398.11
| Professional | | $204.17 | $263.03 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $295.12
| Facility | | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $478.63 / $741.31
| Professional | | $316.23 | $478.63 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $616.60 / $977.24
| Facility | | $363.08 | $616.60 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $457.09 / $891.25
| Facility | | $239.88 | $457.09 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $239.88 / $537.03
| Professional | | $194.98 | $239.88 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $446.68
| Facility | | $269.15 | $269.15 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $295.12 / $446.68
| Professional | | $269.15 | $295.12 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $295.12 / $354.81
| Facility | | $239.88 | $295.12 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $177.83 / $446.68
| Professional | | $123.03 | $177.83 | $446.68 |