- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $331.13
| Facility | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $295.12 / $371.54
| Professional | | $112.20 | $295.12 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $436.52 / $1,000.00
| Professional | | $288.40 | $436.52 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $398.11 / $549.54
| Facility | | $295.12 | $398.11 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $588.84 / $870.96
| Professional | | $208.93 | $588.84 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $302.00 / $467.74
| Facility | | $177.83 | $302.00 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $331.13 / $870.96
| Facility | | $162.18 | $331.13 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $501.19 / $1,862.09
| Professional | | $288.40 | $501.19 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $67.61 / $125.89
| Professional | | $33.11 | $67.61 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $758.58
| Professional | | $676.08 | $676.08 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $691.83 / $1,071.52
| Professional | | $363.08 | $691.83 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,862.09 / $1,862.09
| Facility | | $724.44 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $1,348.96 / $1,862.09
| Professional | | $371.54 | $1,348.96 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Facility | | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $190.55 / $213.80
| Professional | | $169.82 | $190.55 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $1,000.00 / $1,318.26
| Facility | | $354.81 | $1,000.00 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $436.52 / $870.96
| Professional | | $288.40 | $436.52 | $870.96 |