- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $109.65 / $181.97
| Professional | | $93.33 | $109.65 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $363.08
| Facility | | $218.78 | $218.78 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $204.17 / $245.47
| Professional | | $181.97 | $204.17 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $512.86 / $1,071.52
| Facility | | $169.82 | $512.86 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $316.23 / $416.87
| Professional | | $144.54 | $316.23 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $181.97 / $275.42
| Facility | | $109.65 | $181.97 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $213.80 / $263.03
| Professional | | $194.98 | $213.80 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $213.80 / $1,000.00
| Facility | | $123.03 | $213.80 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $144.54 / $245.47
| Professional | | $100.00 | $144.54 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $100.00
| Professional | | $54.95 | $70.79 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $251.19 / $436.52
| Professional | | $154.88 | $251.19 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $331.13 / $602.56
| Professional | | $218.78 | $331.13 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $436.52 / $1,000.00
| Facility | | $169.82 | $436.52 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $234.42 / $1,096.48
| Professional | | $144.54 | $234.42 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $144.54 / $218.78
| Facility | | $114.82 | $144.54 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $107.15 / $177.83
| Professional | | $83.18 | $107.15 | $177.83 |