- 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 / $154.88
| Professional | | $112.20 | $112.20 | $154.88 |
- 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
- $181.97 / $363.08 / $426.58
| Professional | | $181.97 | $363.08 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $223.87 / $467.74
| Professional | | $112.20 | $223.87 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $380.19 / $512.86
| Facility | | $128.82 | $380.19 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $467.74
| Professional | | $128.82 | $128.82 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $398.11 / $467.74
| Professional | | $147.91 | $398.11 | $467.74 |
- 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
- $380.19 / $380.19 / $549.54
| Professional | | $380.19 | $380.19 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.33 / $331.13 / $549.54
| Facility | | $0.33 | $331.13 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $331.13
| Professional | | $125.89 | $125.89 | $331.13 |
- 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 |