- 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
- $87.10 / $194.98 / $1,288.25
| Professional | | $87.10 | $194.98 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $295.12 / $295.12
| Professional | | $269.15 | $295.12 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $338.84
| Facility | | $169.82 | $169.82 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $354.81 / $524.81
| Professional | | $169.82 | $354.81 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $331.13 / $1,412.54
| Facility | | $194.98 | $331.13 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $177.83 / $302.00
| Professional | | $100.00 | $177.83 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $812.83
| Professional | | $331.13 | $331.13 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $338.84
| Facility | | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $758.58 / $812.83
| Professional | | $416.87 | $758.58 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $208.93 / $316.23
| Facility | | $177.83 | $208.93 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $151.36 / $239.88
| Professional | | $109.65 | $151.36 | $239.88 |