- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $100.00 / $257.04
| Facility | | $81.28 | $100.00 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $109.65 / $234.42
| Professional | | $81.28 | $109.65 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $218.78
| Facility | | $204.17 | $204.17 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $257.04
| Professional | | $123.03 | $123.03 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $141.25
| Professional | | $107.15 | $107.15 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $134.90 / $134.90
| Facility | | $89.13 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $134.90
| Professional | | $100.00 | $100.00 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $204.17 / $288.40
| Professional | | $154.88 | $204.17 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $134.90 / $204.17
| Professional | | $112.20 | $134.90 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $138.04 / $257.04
| Facility | | $83.18 | $138.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $120.23 / $257.04
| Professional | | $109.65 | $120.23 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $169.82 / $588.84
| Facility | | $117.49 | $169.82 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $169.82 / $588.84
| Professional | | $117.49 | $169.82 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $100.00 / $204.17
| Facility | | $63.10 | $100.00 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $100.00 / $165.96
| Professional | | $93.33 | $100.00 | $165.96 |