- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $380.19 / $758.58
| Facility | | $151.36 | $380.19 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $158.49 / $239.88
| Professional | | $131.83 | $158.49 | $239.88 |
- 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
- $173.78 / $190.55 / $213.80
| Professional | | $173.78 | $190.55 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $501.19 / $1,047.13
| Facility | | $204.17 | $501.19 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $309.03
| Professional | | $97.72 | $123.03 | $309.03 |
- 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 / $223.87 / $346.74
| Facility | | $162.18 | $223.87 | $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
- $173.78 / $239.88 / $10,000.00
| Facility | | $173.78 | $239.88 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $239.88 / $10,000.00
| Professional | | $173.78 | $239.88 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $204.17 / $245.47
| Facility | | $120.23 | $204.17 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $102.33 / $223.87
| Professional | | $85.11 | $102.33 | $223.87 |