- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $165.96 / $181.97
| Facility | | $158.49 | $165.96 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $112.20 / $181.97
| Professional | | $91.20 | $112.20 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $239.88
| Facility | | $169.82 | $169.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $251.19 / $316.23
| Professional | | $169.82 | $251.19 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $288.40 / $346.74
| Professional | | $204.17 | $288.40 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $295.12 / $1,000.00
| Facility | | $169.82 | $295.12 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $144.54 / $363.08
| Professional | | $100.00 | $144.54 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $275.42 / $575.44
| Professional | | $234.42 | $275.42 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $239.88
| Facility | | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $363.08 / $363.08
| Professional | | $223.87 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $218.78 / $512.86
| Facility | | $95.50 | $218.78 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $114.82 / $204.17
| Professional | | $95.50 | $114.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $213.80 / $213.80
| Professional | | $169.82 | $213.80 | $213.80 |