- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $154.88
| Facility | | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $120.23 / $181.97
| Professional | | $87.10 | $120.23 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Facility | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $446.68 / $549.54
| Professional | | $194.98 | $446.68 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $194.98 / $263.03
| Facility | | $151.36 | $194.98 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $208.93 / $281.84
| Professional | | $190.55 | $208.93 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $251.19 / $257.04
| Facility | | $204.17 | $251.19 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $257.04 / $281.84
| Professional | | $229.09 | $257.04 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $204.17 / $295.12
| Facility | | $138.04 | $204.17 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $223.87 / $275.42
| Professional | | $79.43 | $223.87 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $407.38 / $1,000.00
| Facility | | $213.80 | $407.38 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $288.40 / $288.40
| Professional | | $257.04 | $288.40 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $323.59
| Facility | | $87.10 | $109.65 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $100.00 / $190.55
| Professional | | $81.28 | $100.00 | $190.55 |