- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $158.49
| Professional | | $112.20 | $112.20 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $245.47 / $302.00
| Facility | | $190.55 | $245.47 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $190.55 / $229.09
| Professional | | $144.54 | $190.55 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $478.63 / $977.24
| Professional | | $112.20 | $478.63 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $213.80 / $1,023.29
| Facility | | $128.82 | $213.80 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $741.31
| Professional | | $128.82 | $128.82 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $213.80 / $741.31
| Professional | | $147.91 | $213.80 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $245.47 / $302.00
| Facility | | $204.17 | $245.47 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $741.31 / $741.31
| Professional | | $354.81 | $741.31 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.18 / $177.83 / $295.12
| Facility | | $0.18 | $177.83 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $177.83
| Professional | | $125.89 | $125.89 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Professional | | $112.20 | $112.20 | $112.20 |