- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $173.78 / $691.83
| Facility | | $112.20 | $173.78 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $134.90 / $426.58
| Professional | | $120.23 | $134.90 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Professional | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Professional | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $158.49 / $50,118.72
| Facility | | $134.90 | $158.49 | $50,118.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $707.95
| Professional | | $158.49 | $158.49 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.10 / $151.36 / $263.03
| Facility | | $0.10 | $151.36 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $138.04
| Facility | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $151.36
| Professional | | $138.04 | $138.04 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $173.78 / $316.23
| Facility | | $158.49 | $173.78 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Professional | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $50,118.72 / $75,857.76
| Facility | | $288.40 | $50,118.72 | $75,857.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Facility | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $141.25 / $199.53
| Professional | | $104.71 | $141.25 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $138.04 / $144.54
| Facility | | $97.72 | $138.04 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $138.04 / $165.96
| Professional | | $93.33 | $138.04 | $165.96 |