- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $407.38 / $870.96
| Facility | | $128.82 | $407.38 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $158.49 / $316.23
| Professional | | $114.82 | $158.49 | $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
- $93.33 / $93.33 / $165.96
| Professional | | $93.33 | $93.33 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $549.54 / $1,174.90
| Professional | | $138.04 | $549.54 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $426.58 / $794.33
| Facility | | $275.42 | $426.58 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $128.82 / $354.81
| Professional | | $91.20 | $128.82 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $208.93 / $257.04
| Professional | | $173.78 | $208.93 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Professional | | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $295.12 / $407.38
| Facility | | $154.88 | $295.12 | $407.38 |
- 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
- $165.96 / $245.47 / $10,000.00
| Facility | | $165.96 | $245.47 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $245.47 / $10,000.00
| Professional | | $162.18 | $245.47 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $173.78 / $288.40
| Facility | | $138.04 | $173.78 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $173.78 / $371.54
| Professional | | $104.71 | $173.78 | $371.54 |