- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $331.13 / $891.25
| Facility | | $112.20 | $331.13 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $138.04 / $281.84
| Professional | | $112.20 | $138.04 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $645.65
| Facility | | $151.36 | $151.36 | $645.65 |
- 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
- $120.23 / $501.19 / $1,047.13
| Professional | | $120.23 | $501.19 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $380.19 / $676.08
| Facility | | $234.42 | $380.19 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $112.20 / $316.23
| Professional | | $83.18 | $112.20 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $177.83 / $223.87
| Professional | | $151.36 | $177.83 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $295.12
| Professional | | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $263.03 / $407.38
| Facility | | $138.04 | $263.03 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $316.23
| Professional | | $120.23 | $120.23 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $218.78 / $10,000.00
| Facility | | $147.91 | $218.78 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $218.78 / $10,000.00
| Professional | | $147.91 | $218.78 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $151.36 / $257.04
| Facility | | $125.89 | $151.36 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $151.36 / $338.84
| Professional | | $91.20 | $151.36 | $338.84 |