- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Facility | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $128.82 / $194.98
| Professional | | $95.50 | $128.82 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $186.21 / $223.87
| Facility | | $186.21 | $186.21 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $181.97
| Professional | | $169.82 | $169.82 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Facility | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $134.90
| Professional | | $91.20 | $91.20 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $112.20 / $144.54
| Professional | | $104.71 | $112.20 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $194.98 / $331.13
| Facility | | $72.44 | $194.98 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $218.78 / $229.09
| Professional | | $0.60 | $218.78 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $100.00 / $181.97
| Facility | | $67.61 | $100.00 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $112.20 / $162.18
| Professional | | $83.18 | $112.20 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,258.93 / $1,584.89
| Professional | | $1,258.93 | $1,258.93 | $1,584.89 |