- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $758.58 / $758.58
| Facility | | $213.80 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $213.80 / $446.68
| Professional | | $165.96 | $213.80 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $288.40 / $691.83
| Professional | | $186.21 | $288.40 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $630.96 / $1,000.00
| Facility | | $537.03 | $630.96 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $489.78 / $588.84
| Professional | | $194.98 | $489.78 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $218.78 / $416.87
| Facility | | $177.83 | $218.78 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $426.58 / $588.84
| Professional | | $363.08 | $426.58 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $218.78 / $436.52
| Facility | | $177.83 | $218.78 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $309.03 / $1,348.96
| Professional | | $181.97 | $309.03 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $70.79
| Professional | | $32.36 | $33.11 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $346.74 / $524.81
| Professional | | $229.09 | $346.74 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $489.78 / $707.95
| Professional | | $309.03 | $489.78 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $467.74 / $1,258.93
| Facility | | $323.59 | $467.74 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $741.31 / $1,348.96
| Professional | | $190.55 | $741.31 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $245.47 / $245.47
| Professional | | $245.47 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $338.84 / $707.95
| Professional | | $245.47 | $338.84 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $302.00 / $851.14
| Professional | | $95.50 | $302.00 | $851.14 |