- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $302.00 / $302.00
| Facility | | $77.62 | $302.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $95.50 / $158.49
| Professional | | $77.62 | $95.50 | $158.49 |
- 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
- $190.55 / $190.55 / $190.55
| Professional | | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $194.98
| Facility | | $128.82 | $128.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $128.82
| Professional | | $95.50 | $95.50 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $251.19 / $371.54
| Professional | | $177.83 | $251.19 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Facility | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $134.90 / $194.98
| Professional | | $117.49 | $134.90 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Professional | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $77.62
| Facility | | $77.62 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $95.50 / $134.90
| Professional | | $77.62 | $95.50 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $61.66 / $295.12
| Professional | | $61.66 | $61.66 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $181.97
| Facility | | $134.90 | $134.90 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $177.83 / $186.21
| Professional | | $134.90 | $177.83 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $234.42 / $269.15
| Facility | | $85.11 | $234.42 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $95.50 / $194.98
| Professional | | $72.44 | $95.50 | $194.98 |