- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $229.09
| Facility | | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $181.97 / $229.09
| Professional | | $114.82 | $181.97 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $218.78
| Professional | | $199.53 | $199.53 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $158.49 / $162.18
| Facility | | $114.82 | $158.49 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $204.17
| Professional | | $117.49 | $117.49 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $128.82 / $199.53
| Professional | | $120.23 | $128.82 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $234.42 / $398.11
| Facility | | $112.20 | $234.42 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $128.82 / $213.80
| Facility | | $95.50 | $128.82 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $128.82 / $190.55
| Professional | | $100.00 | $128.82 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,412.54 / $1,412.54
| Facility | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |