- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $114.82
| Facility | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $114.82 / $158.49
| Professional | | $87.10 | $114.82 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $389.05
| Facility | | $234.42 | $234.42 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $218.78 / $257.04
| Professional | | $194.98 | $218.78 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $537.03 / $1,148.15
| Facility | | $117.49 | $537.03 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $331.13 / $446.68
| Professional | | $85.11 | $331.13 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $190.55 / $288.40
| Facility | | $114.82 | $190.55 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $269.15 / $331.13
| Professional | | $208.93 | $269.15 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $229.09 / $1,000.00
| Facility | | $114.82 | $229.09 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $114.82 / $251.19
| Professional | | $91.20 | $114.82 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $120.23
| Professional | | $54.95 | $70.79 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $371.54 / $371.54
| Facility | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $263.03 / $457.09
| Professional | | $165.96 | $263.03 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $354.81 / $588.84
| Professional | | $234.42 | $354.81 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $467.74 / $1,174.90
| Facility | | $117.49 | $467.74 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $169.82 / $1,202.26
| Professional | | $85.11 | $169.82 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $109.65 / $234.42
| Facility | | $63.10 | $109.65 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $114.82 / $190.55
| Professional | | $75.86 | $114.82 | $190.55 |