- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $169.82 / $316.23
| Facility | | $104.71 | $169.82 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $169.82 / $251.19
| Professional | | $104.71 | $169.82 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $269.15
| Facility | | $251.19 | $251.19 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $416.87
| Professional | | $199.53 | $199.53 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $181.97
| Professional | | $181.97 | $181.97 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $213.80 / $213.80
| Facility | | $144.54 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $213.80
| Professional | | $158.49 | $158.49 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $269.15 / $389.05
| Professional | | $169.82 | $269.15 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $229.09 / $346.74
| Professional | | $186.21 | $229.09 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $218.78 / $380.19
| Facility | | $109.65 | $218.78 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $213.80 / $316.23
| Professional | | $186.21 | $213.80 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $263.03 / $1,000.00
| Facility | | $177.83 | $263.03 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $263.03 / $1,000.00
| Professional | | $177.83 | $263.03 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $169.82 / $257.04
| Facility | | $109.65 | $169.82 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $169.82 / $275.42
| Professional | | $154.88 | $169.82 | $275.42 |