- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $190.55
| Facility | | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $190.55 / $190.55
| Professional | | $138.04 | $190.55 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $323.59 / $602.56
| Facility | | $128.82 | $323.59 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $181.97
| Professional | | $181.97 | $181.97 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $416.87 / $1,071.52
| Facility | | $177.83 | $416.87 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Professional | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $190.55 / $269.15
| Facility | | $138.04 | $190.55 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $190.55 / $263.03
| Professional | | $138.04 | $190.55 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $131.83
| Professional | | $117.49 | $117.49 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $204.17 / $562.34
| Facility | | $141.25 | $204.17 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Professional | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $151.36 / $234.42
| Facility | | $141.25 | $151.36 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $162.18 / $199.53
| Professional | | $134.90 | $162.18 | $199.53 |