- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Professional | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $275.42 / $478.63
| Professional | | $269.15 | $275.42 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $331.13
| Facility | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $53,703.18
| Facility | | $223.87 | $223.87 | $53,703.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $223.87
| Professional | | $162.18 | $162.18 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $331.13 / $331.13
| Professional | | $269.15 | $331.13 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $354.81
| Facility | | $331.13 | $331.13 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $331.13
| Professional | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $50,118.72 / $75,857.76
| Facility | | $724.44 | $50,118.72 | $75,857.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $186.21 / $234.42
| Facility | | $141.25 | $186.21 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $199.53 / $338.84
| Professional | | $131.83 | $199.53 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $331.13 / $398.11
| Facility | | $295.12 | $331.13 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $331.13 / $331.13
| Professional | | $295.12 | $331.13 | $331.13 |