- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $186.21
| Facility | | $123.03 | $123.03 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $102.33 / $173.78
| Professional | | $81.28 | $102.33 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $218.78
| Facility | | $123.03 | $123.03 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $223.87 / $275.42
| Professional | | $123.03 | $223.87 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $190.55 / $204.17
| Professional | | $162.18 | $190.55 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $251.19 / $1,000.00
| Facility | | $134.90 | $251.19 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $123.03 / $323.59
| Professional | | $93.33 | $123.03 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $223.87 / $295.12
| Professional | | $213.80 | $223.87 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $218.78
| Facility | | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $323.59 / $323.59
| Professional | | $218.78 | $323.59 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $199.53 / $512.86
| Facility | | $74.13 | $199.53 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $97.72 / $186.21
| Professional | | $91.20 | $97.72 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $190.55 / $190.55
| Professional | | $151.36 | $190.55 | $190.55 |