- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $575.44 / $954.99
| Facility | | $204.17 | $575.44 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $181.97 / $645.65
| Professional | | $162.18 | $181.97 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,445.44 / $5,011.87
| Facility | | $1,096.48 | $1,445.44 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Professional | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $363.08 / $758.58
| Facility | | $213.80 | $363.08 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $234.42 / $501.19
| Professional | | $128.82 | $234.42 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $194.98 / $295.12
| Professional | | $154.88 | $194.98 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $218.78
| Facility | | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $354.81 / $562.34
| Professional | | $239.88 | $354.81 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $1,000.00 / $1,047.13
| Facility | | $331.13 | $1,000.00 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $575.44 / $758.58
| Facility | | $186.21 | $575.44 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $177.83 / $263.03
| Professional | | $162.18 | $177.83 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $331.13
| Facility | | $144.54 | $144.54 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $218.78 / $489.78
| Professional | | $144.54 | $218.78 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $218.78 / $263.03
| Facility | | $181.97 | $218.78 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $131.83 / $331.13
| Professional | | $93.33 | $131.83 | $331.13 |