- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $213.80 / $457.09
| Professional | | $165.96 | $213.80 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $194.98 / $346.74
| Professional | | $147.91 | $194.98 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $269.15 / $467.74
| Professional | | $190.55 | $269.15 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Facility | | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $251.19 / $457.09
| Professional | | $181.97 | $251.19 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $251.19
| Professional | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $229.09 / $363.08
| Facility | | $186.21 | $229.09 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $457.09
| Professional | | $128.82 | $128.82 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $288.40 / $316.23
| Professional | | $194.98 | $288.40 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $218.78
| Facility | | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $199.53 / $346.74
| Professional | | $154.88 | $199.53 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,348.96 / $1,659.59
| Professional | | $1,348.96 | $1,348.96 | $1,659.59 |