- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $138.04 / $245.47
| Facility | | $104.71 | $138.04 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $107.15 / $177.83
| Professional | | $104.71 | $107.15 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $109.65
| Facility | | $104.71 | $104.71 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $97.72
| Facility | | $93.33 | $93.33 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Professional | | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $138.04 / $151.36
| Facility | | $97.72 | $138.04 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $446.68
| Professional | | $104.71 | $104.71 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $128.82 / $354.81
| Facility | | $97.72 | $128.82 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $138.04
| Professional | | $114.82 | $114.82 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $109.65
| Facility | | $104.71 | $104.71 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $109.65
| Professional | | $104.71 | $104.71 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $50,118.72 / $75,857.76
| Facility | | $134.90 | $50,118.72 | $75,857.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $104.71 / $165.96
| Facility | | $100.00 | $104.71 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $107.15 / $177.83
| Professional | | $95.50 | $107.15 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $123.03
| Facility | | $104.71 | $104.71 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $109.65 / $125.89
| Professional | | $104.71 | $109.65 | $125.89 |