- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Facility | | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $97.72 / $169.82
| Professional | | $87.10 | $97.72 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $323.59
| Facility | | $194.98 | $194.98 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $218.78
| Professional | | $181.97 | $181.97 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $457.09 / $954.99
| Facility | | $123.03 | $457.09 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $275.42 / $371.54
| Professional | | $91.20 | $275.42 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $158.49 / $239.88
| Facility | | $97.72 | $158.49 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $190.55 / $234.42
| Professional | | $109.65 | $190.55 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $190.55 / $1,000.00
| Facility | | $97.72 | $190.55 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $109.65 / $218.78
| Professional | | $89.13 | $109.65 | $218.78 |
- 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
- $309.03 / $309.03 / $309.03
| Facility | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $218.78 / $380.19
| Professional | | $138.04 | $218.78 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $302.00 / $602.56
| Professional | | $194.98 | $302.00 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $389.05 / $1,096.48
| Facility | | $123.03 | $389.05 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $181.97 / $1,288.25
| Professional | | $91.20 | $181.97 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $112.20 / $194.98
| Facility | | $74.13 | $112.20 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $95.50 / $169.82
| Professional | | $75.86 | $95.50 | $169.82 |