- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $426.58 / $831.76
| Facility | | $151.36 | $426.58 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $162.18 / $354.81
| Professional | | $125.89 | $162.18 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $870.96
| Facility | | $204.17 | $204.17 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $141.25
| Professional | | $81.28 | $81.28 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $870.96 / $1,819.70
| Professional | | $181.97 | $870.96 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $489.78 / $912.01
| Facility | | $204.17 | $489.78 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $123.03 / $331.13
| Professional | | $93.33 | $123.03 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $223.87 / $281.84
| Professional | | $204.17 | $223.87 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $245.47 / $346.74
| Facility | | $162.18 | $245.47 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $426.58
| Professional | | $131.83 | $131.83 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $245.47 / $10,000.00
| Facility | | $165.96 | $245.47 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $245.47 / $10,000.00
| Professional | | $165.96 | $245.47 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $204.17 / $245.47
| Facility | | $114.82 | $204.17 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $102.33 / $218.78
| Professional | | $79.43 | $102.33 | $218.78 |