- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $165.96 / $194.98
| Facility | | $107.15 | $165.96 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $213.80 / $512.86
| Professional | | $114.82 | $213.80 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $131.83 / $257.04
| Professional | | $112.20 | $131.83 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $112.20 / $275.42
| Professional | | $95.50 | $112.20 | $275.42 |
- 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
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $218.78
| Facility | | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $204.17 / $426.58
| Professional | | $123.03 | $204.17 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $309.03
| Facility | | $125.89 | $125.89 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $177.83 / $269.15
| Professional | | $131.83 | $177.83 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $147.91 / $295.12
| Professional | | $85.11 | $147.91 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $190.55 / $295.12
| Professional | | $158.49 | $190.55 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $204.17 / $398.11
| Professional | | $165.96 | $204.17 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $147.91 / $1,862.09
| Facility | | $120.23 | $147.91 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $218.78 / $1,000.00
| Professional | | $151.36 | $218.78 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $154.88 / $302.00
| Professional | | $114.82 | $154.88 | $302.00 |