- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $389.05 / $512.86
| Facility | | $154.88 | $389.05 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $158.49 / $245.47
| Professional | | $134.90 | $158.49 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $891.25
| Facility | | $208.93 | $208.93 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $138.04
| Professional | | $83.18 | $83.18 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $457.09 / $933.25
| Professional | | $165.96 | $457.09 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $407.38 / $1,071.52
| Facility | | $208.93 | $407.38 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $128.82 / $331.13
| Professional | | $102.33 | $128.82 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $229.09 / $288.40
| Professional | | $208.93 | $229.09 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $208.93 / $354.81
| Facility | | $154.88 | $208.93 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $436.52
| Professional | | $134.90 | $134.90 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $239.88 / $10,000.00
| Facility | | $177.83 | $239.88 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $251.19 / $10,000.00
| Professional | | $177.83 | $251.19 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $208.93 / $251.19
| Facility | | $123.03 | $208.93 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $104.71 / $229.09
| Professional | | $87.10 | $104.71 | $229.09 |