- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $204.17 / $691.83
| Facility | | $165.96 | $204.17 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $165.96 / $239.88
| Professional | | $125.89 | $165.96 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $467.74 / $660.69
| Facility | | $407.38 | $467.74 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $147.91 / $173.78
| Professional | | $93.33 | $147.91 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $436.52 / $954.99
| Facility | | $138.04 | $436.52 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $97.72 / $281.84
| Professional | | $77.62 | $97.72 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $302.00
| Professional | | $109.65 | $109.65 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $151.36 / $275.42
| Facility | | $104.71 | $151.36 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $169.82 / $186.21
| Professional | | $134.90 | $169.82 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $208.93 / $245.47
| Facility | | $87.10 | $208.93 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $104.71 / $208.93
| Professional | | $87.10 | $104.71 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |