- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $109.65 / $109.65
| Professional | | $75.86 | $109.65 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $302.00 / $302.00
| Facility | | $165.96 | $302.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $165.96 / $223.87
| Professional | | $138.04 | $165.96 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $602.56
| Facility | | $100.00 | $100.00 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $186.21 / $316.23
| Professional | | $100.00 | $186.21 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $147.91 / $208.93
| Facility | | $57.54 | $147.91 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $208.93 / $724.44
| Facility | | $57.54 | $208.93 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $100.00 / $169.82
| Professional | | $75.86 | $100.00 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $9.77 / $54.95 / $120.23
| Professional | | $9.77 | $54.95 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $151.36 / $281.84
| Professional | | $89.13 | $151.36 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $33.88 / $45.71
| Professional | | $21.88 | $33.88 | $45.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $323.59 / $724.44
| Facility | | $100.00 | $323.59 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $100.00 / $114.82
| Professional | | $85.11 | $100.00 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $8.32 / $66.07 / $123.03
| Facility | | $8.32 | $66.07 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $97.72 / $169.82
| Professional | | $63.10 | $97.72 | $169.82 |