- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $162.18 / $645.65
| Facility | | $112.20 | $162.18 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $117.49 / $141.25
| Professional | | $97.72 | $117.49 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $100.00
| Facility | | $97.72 | $97.72 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Professional | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $128.82
| Facility | | $117.49 | $117.49 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Professional | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $125.89 / $50,118.72
| Facility | | $123.03 | $125.89 | $50,118.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $630.96
| Professional | | $120.23 | $120.23 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $208.93
| Facility | | $120.23 | $120.23 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $138.04
| Professional | | $120.23 | $120.23 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $125.89 / $131.83
| Facility | | $120.23 | $125.89 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $125.89 / $125.89
| Professional | | $120.23 | $125.89 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $50,118.72 / $75,857.76
| Facility | | $257.04 | $50,118.72 | $75,857.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $107.15 / $107.15
| Facility | | $97.72 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $120.23 / $165.96
| Professional | | $117.49 | $120.23 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $125.89 / $138.04
| Facility | | $120.23 | $125.89 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $125.89 / $151.36
| Professional | | $120.23 | $125.89 | $151.36 |