- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $489.78 / $489.78
| Facility | | $120.23 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $537.03
| Professional | | $489.78 | $489.78 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $794.33
| Professional | | $489.78 | $489.78 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $165.96 / $831.76
| Facility | | $138.04 | $165.96 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $144.54
| Professional | | $125.89 | $125.89 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $537.03 / $1,258.93
| Facility | | $151.36 | $537.03 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $707.95 / $831.76
| Professional | | $158.49 | $707.95 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $501.19
| Facility | | $489.78 | $489.78 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $501.19 / $501.19
| Professional | | $489.78 | $501.19 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $50,118.72 / $75,857.76
| Facility | | $630.96 | $50,118.72 | $75,857.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $912.01
| Professional | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $537.03 / $831.76
| Facility | | $537.03 | $537.03 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $489.78 / $1,000.00
| Professional | | $125.89 | $489.78 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $537.03
| Facility | | $489.78 | $489.78 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $501.19 / $501.19
| Professional | | $489.78 | $501.19 | $501.19 |