- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $323.59 / $323.59
| Facility | | $83.18 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $112.20 / $151.36
| Professional | | $83.18 | $112.20 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5,011.87 / $8,511.38 / $77,624.71
| Facility | | $5,011.87 | $8,511.38 | $77,624.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $204.17
| Facility | | $134.90 | $134.90 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $134.90
| Professional | | $100.00 | $100.00 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $269.15 / $389.05
| Professional | | $190.55 | $269.15 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $144.54 / $204.17
| Professional | | $123.03 | $144.54 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $83.18
| Facility | | $83.18 | $83.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $112.20 / $144.54
| Professional | | $83.18 | $112.20 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $275.42 / $398.11
| Professional | | $0.60 | $275.42 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $144.54 / $218.78
| Facility | | $72.44 | $144.54 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $190.55 / $218.78
| Professional | | $144.54 | $190.55 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $275.42 / $316.23
| Facility | | $93.33 | $275.42 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $100.00 / $204.17
| Professional | | $83.18 | $100.00 | $204.17 |