- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $77.62
| Facility | | $77.62 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $79.43 / $120.23
| Professional | | $60.26 | $79.43 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $263.03
| Facility | | $158.49 | $158.49 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $147.91 / $177.83
| Professional | | $131.83 | $147.91 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $363.08 / $776.25
| Facility | | $87.10 | $363.08 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $223.87 / $302.00
| Professional | | $63.10 | $223.87 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $128.82 / $194.98
| Facility | | $77.62 | $128.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $194.98 / $245.47
| Professional | | $141.25 | $194.98 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $154.88 / $741.31
| Facility | | $77.62 | $154.88 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $83.18 / $177.83
| Professional | | $69.18 | $83.18 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $70.79 / $85.11
| Professional | | $50.12 | $70.79 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $177.83 / $309.03
| Professional | | $112.20 | $177.83 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $239.88 / $436.52
| Professional | | $158.49 | $239.88 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $316.23 / $870.96
| Facility | | $87.10 | $316.23 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $125.89 / $1,000.00
| Professional | | $63.10 | $125.89 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $81.28 / $158.49
| Facility | | $53.70 | $81.28 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $77.62 / $131.83
| Professional | | $53.70 | $77.62 | $131.83 |