- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $131.83 / $131.83
| Facility | | $16.98 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $123.03 / $144.54
| Professional | | $16.98 | $123.03 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $165.96 / $234.42
| Professional | | $120.23 | $165.96 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $147.91 / $154.88
| Professional | | $131.83 | $147.91 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $15.85 / $190.55
| Facility | | $15.85 | $15.85 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $151.36 / $281.84
| Professional | | $109.65 | $151.36 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $151.36 / $177.83
| Professional | | $120.23 | $151.36 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $18.62 / $117.49 / $181.97
| Facility | | $18.62 | $117.49 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $43.65 / $43.65
| Professional | | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $173.78 / $10,000.00
| Facility | | $31.62 | $173.78 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $173.78 / $10,000.00
| Professional | | $31.62 | $173.78 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $134.90 / $239.88
| Professional | | $95.50 | $134.90 | $239.88 |