- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $758.58 / $1,230.27
| Facility | | $275.42 | $758.58 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $234.42 / $851.14
| Professional | | $173.78 | $234.42 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,412.54 / $5,011.87
| Facility | | $1,047.13 | $1,412.54 | $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
- $281.84 / $478.63 / $1,000.00
| Facility | | $281.84 | $478.63 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $251.19 / $436.52
| Professional | | $134.90 | $251.19 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $263.03 / $389.05
| Professional | | $204.17 | $263.03 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $288.40
| Facility | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $346.74 / $549.54
| Professional | | $218.78 | $346.74 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $562.34 / $1,000.00
| Facility | | $234.42 | $562.34 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $234.42 / $363.08
| Professional | | $173.78 | $234.42 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $323.59 / $416.87
| Facility | | $57.54 | $323.59 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $323.59 / $416.87
| Professional | | $57.54 | $323.59 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $288.40 / $346.74
| Facility | | $173.78 | $288.40 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $173.78 / $389.05
| Professional | | $123.03 | $173.78 | $389.05 |