- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Facility | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $104.71 / $213.80
| Professional | | $69.18 | $104.71 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $338.84
| Facility | | $204.17 | $204.17 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $229.09
| Professional | | $190.55 | $190.55 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $245.47 / $323.59
| Facility | | $245.47 | $245.47 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $457.09 / $1,023.29
| Facility | | $125.89 | $457.09 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $295.12 / $389.05
| Professional | | $93.33 | $295.12 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $165.96 / $239.88
| Facility | | $102.33 | $165.96 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $223.87 / $245.47
| Professional | | $194.98 | $223.87 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $204.17 / $933.25
| Facility | | $109.65 | $204.17 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $107.15 / $229.09
| Professional | | $91.20 | $107.15 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $61.66 / $70.79
| Professional | | $50.12 | $61.66 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $239.88 / $501.19
| Professional | | $177.83 | $239.88 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $309.03 / $562.34
| Professional | | $204.17 | $309.03 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $407.38 / $933.25
| Facility | | $125.89 | $407.38 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $186.21 / $1,000.00
| Professional | | $93.33 | $186.21 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $104.71 / $204.17
| Facility | | $63.10 | $104.71 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $104.71 / $407.38
| Professional | | $79.43 | $104.71 | $407.38 |