- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $691.83 / $954.99
| Facility | | $213.80 | $691.83 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $251.19 / $562.34
| Professional | | $204.17 | $251.19 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $354.81 / $1,000.00
| Facility | | $229.09 | $354.81 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $309.03 / $912.01
| Professional | | $186.21 | $309.03 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $389.05 / $616.60
| Facility | | $309.03 | $389.05 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $288.40
| Professional | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $239.88 / $489.78
| Facility | | $204.17 | $239.88 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $331.13 / $616.60
| Professional | | $173.78 | $331.13 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $1,778.28 / $8,511.38
| Facility | | $162.18 | $1,778.28 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $524.81
| Professional | | $446.68 | $446.68 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $501.19
| Professional | | $309.03 | $309.03 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $354.81 / $1,000.00
| Facility | | $229.09 | $354.81 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $309.03 / $912.01
| Professional | | $186.21 | $309.03 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $309.03 / $371.54
| Facility | | $186.21 | $309.03 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $309.03 / $588.84
| Professional | | $186.21 | $309.03 | $588.84 |