- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $107.15 / $144.54
| Professional | | $87.10 | $107.15 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $354.81
| Facility | | $213.80 | $213.80 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $199.53 / $239.88
| Professional | | $194.98 | $199.53 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $501.19 / $1,047.13
| Facility | | $144.54 | $501.19 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $309.03 / $407.38
| Professional | | $104.71 | $309.03 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $173.78 / $269.15
| Facility | | $104.71 | $173.78 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $208.93 / $257.04
| Professional | | $120.23 | $208.93 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $208.93 / $933.25
| Facility | | $107.15 | $208.93 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $104.71 / $229.09
| Professional | | $85.11 | $104.71 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $100.00
| Professional | | $54.95 | $70.79 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $338.84
| Facility | | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $245.47 / $426.58
| Professional | | $151.36 | $245.47 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $323.59 / $549.54
| Professional | | $213.80 | $323.59 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $426.58 / $1,096.48
| Facility | | $144.54 | $426.58 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $190.55 / $1,258.93
| Professional | | $104.71 | $190.55 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $100.00 / $213.80
| Facility | | $66.07 | $100.00 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $104.71 / $173.78
| Professional | | $70.79 | $104.71 | $173.78 |