- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $190.55 / $407.38
| Facility | | $77.62 | $190.55 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $186.21 / $346.74
| Professional | | $138.04 | $186.21 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $338.84
| Professional | | $257.04 | $257.04 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $1,000.00 / $1,949.84
| Facility | | $446.68 | $1,000.00 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $354.81
| Professional | | $338.84 | $338.84 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $245.47
| Facility | | $218.78 | $218.78 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $218.78 / $380.19
| Professional | | $158.49 | $218.78 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $257.04 / $707.95
| Facility | | $162.18 | $257.04 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $269.15 / $407.38
| Professional | | $169.82 | $269.15 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $245.47
| Facility | | $218.78 | $218.78 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $229.09 / $346.74
| Professional | | $158.49 | $229.09 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $275.42 / $416.87
| Facility | | $120.23 | $275.42 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $158.49 / $239.88
| Professional | | $120.23 | $158.49 | $239.88 |