- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $144.54 / $549.54
| Facility | | $120.23 | $144.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $645.65
| Professional | | $549.54 | $549.54 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $1,096.48
| Professional | | $549.54 | $549.54 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $165.96 / $4,265.80
| Facility | | $138.04 | $165.96 | $4,265.80 |
- 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 / $1,995.26
| Facility | | $151.36 | $537.03 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $1,122.02 / $1,318.26
| Professional | | $158.49 | $1,122.02 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $575.44
| Facility | | $549.54 | $549.54 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $575.44 / $575.44
| Professional | | $549.54 | $575.44 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,630.78 / $50,118.72 / $75,857.76
| Facility | | $3,630.78 | $50,118.72 | $75,857.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,370.32 / $5,370.32 / $5,370.32
| Professional | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $1,096.48 / $3,630.78
| Professional | | $125.89 | $1,096.48 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $616.60
| Facility | | $549.54 | $549.54 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $575.44 / $575.44
| Professional | | $549.54 | $575.44 | $575.44 |