- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $194.98 / $194.98
| Facility | | $120.23 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $190.55 / $234.42
| Professional | | $120.23 | $190.55 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $186.21 / $269.15
| Professional | | $173.78 | $186.21 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $269.15
| Facility | | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $251.19 / $269.15
| Professional | | $199.53 | $251.19 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $177.83 / $426.58
| Facility | | $169.82 | $177.83 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $177.83
| Professional | | $128.82 | $128.82 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $162.18 / $269.15
| Professional | | $60.26 | $162.18 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $162.18 / $257.04
| Professional | | $114.82 | $162.18 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $190.55 / $218.78
| Facility | | $109.65 | $190.55 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $131.83 / $190.55
| Professional | | $104.71 | $131.83 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $269.15
| Professional | | $162.18 | $162.18 | $269.15 |