- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $223.87 / $426.58
| Professional | | $173.78 | $223.87 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $288.40
| Facility | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Professional | | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $831.76 / $1,000.00
| Professional | | $288.40 | $831.76 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $281.84 / $398.11
| Facility | | $223.87 | $281.84 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $302.00 / $416.87
| Professional | | $275.42 | $302.00 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $363.08 / $371.54
| Facility | | $295.12 | $363.08 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $371.54 / $407.38
| Professional | | $316.23 | $371.54 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $323.59 / $478.63
| Facility | | $223.87 | $323.59 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $323.59 / $398.11
| Professional | | $79.43 | $323.59 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $588.84 / $1,479.11
| Facility | | $309.03 | $588.84 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $416.87 / $416.87
| Professional | | $380.19 | $416.87 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $251.19 / $602.56
| Facility | | $173.78 | $251.19 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $186.21 / $354.81
| Professional | | $169.82 | $186.21 | $354.81 |