- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $380.19 / $891.25
| Facility | | $128.82 | $380.19 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $147.91 / $316.23
| Professional | | $114.82 | $147.91 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $741.31
| Facility | | $173.78 | $173.78 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $151.36
| Professional | | $85.11 | $85.11 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $489.78 / $1,047.13
| Professional | | $138.04 | $489.78 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $363.08 / $794.33
| Facility | | $257.04 | $363.08 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $123.03 / $316.23
| Professional | | $95.50 | $123.03 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $204.17 / $257.04
| Professional | | $173.78 | $204.17 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $288.40
| Professional | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $257.04 / $371.54
| Facility | | $154.88 | $257.04 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $363.08
| Professional | | $134.90 | $134.90 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $229.09 / $10,000.00
| Facility | | $154.88 | $229.09 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $229.09 / $10,000.00
| Professional | | $154.88 | $229.09 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $173.78 / $257.04
| Facility | | $125.89 | $173.78 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $173.78 / $346.74
| Professional | | $104.71 | $173.78 | $346.74 |