- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $389.05 / $776.25
| Facility | | $131.83 | $389.05 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $131.83 / $162.18
| Professional | | $123.03 | $131.83 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $758.58
| Facility | | $177.83 | $177.83 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $120.23
| Professional | | $70.79 | $70.79 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $812.83 / $1,202.26
| Professional | | $512.86 | $812.83 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $436.52 / $812.83
| Facility | | $181.97 | $436.52 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $107.15 / $257.04
| Professional | | $83.18 | $107.15 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $213.80 / $263.03
| Professional | | $177.83 | $213.80 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $177.83
| Facility | | $89.13 | $89.13 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $371.54
| Professional | | $114.82 | $114.82 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $218.78 / $10,000.00
| Facility | | $125.89 | $218.78 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $218.78 / $10,000.00
| Professional | | $125.89 | $218.78 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $177.83 / $213.80
| Facility | | $74.13 | $177.83 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $89.13 / $177.83
| Professional | | $74.13 | $89.13 | $177.83 |