- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $436.52 / $436.52
| Facility | | $100.00 | $436.52 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $295.12 / $436.52
| Professional | | $177.83 | $295.12 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $489.78
| Facility | | $467.74 | $467.74 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $380.19
| Professional | | $223.87 | $223.87 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $245.47 / $741.31
| Facility | | $245.47 | $245.47 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $208.93
| Professional | | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $549.54 / $707.95
| Professional | | $416.87 | $549.54 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $467.74
| Professional | | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $309.03 / $478.63
| Facility | | $245.47 | $309.03 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $234.42
| Professional | | $173.78 | $173.78 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $457.09 / $10,000.00
| Facility | | $269.15 | $457.09 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $446.68 / $10,000.00
| Professional | | $269.15 | $446.68 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $467.74 / $467.74
| Facility | | $380.19 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $380.19 / $645.65
| Professional | | $229.09 | $380.19 | $645.65 |