- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Professional | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $263.03 / $660.69
| Facility | | $208.93 | $263.03 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $275.42
| Professional | | $269.15 | $269.15 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $645.65 / $977.24
| Professional | | $398.11 | $645.65 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $229.09
| Facility | | $223.87 | $223.87 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $223.87
| Professional | | $162.18 | $162.18 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $630.96 / $831.76
| Professional | | $141.25 | $630.96 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $281.84 / $281.84
| Facility | | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,348.96 / $1,348.96
| Professional | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $70.79
| Professional | | $54.95 | $54.95 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $239.88
| Facility | | $141.25 | $141.25 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $223.87
| Professional | | $162.18 | $162.18 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $169.82 / $186.21
| Facility | | $28.18 | $169.82 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $169.82 / $338.84
| Professional | | $141.25 | $169.82 | $338.84 |