- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $158.49 / $389.05
| Facility | | $104.71 | $158.49 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $177.83
| Professional | | $104.71 | $104.71 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Facility | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $107.15 / $134.90
| Professional | | $104.71 | $107.15 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $144.54 / $239.88
| Professional | | $100.00 | $144.54 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $109.65 / $169.82
| Facility | | $100.00 | $109.65 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $112.20 / $426.58
| Professional | | $100.00 | $112.20 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $125.89 / $316.23
| Professional | | $117.49 | $125.89 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $169.82 / $223.87
| Professional | | $120.23 | $169.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $186.21 / $223.87
| Professional | | $114.82 | $186.21 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $120.23
| Facility | | $104.71 | $104.71 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $104.71 / $125.89
| Professional | | $100.00 | $104.71 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $114.82 / $114.82
| Facility | | $109.65 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $109.65 / $114.82
| Professional | | $91.20 | $109.65 | $114.82 |