- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Facility | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $107.15 / $208.93
| Professional | | $85.11 | $107.15 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $20.42 / $158.49 / $363.08
| Facility | | $20.42 | $158.49 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $218.78 / $234.42
| Professional | | $169.82 | $218.78 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $199.53
| Facility | | $123.03 | $123.03 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $123.03
| Professional | | $104.71 | $104.71 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $109.65 / $208.93
| Facility | | $85.11 | $109.65 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $138.04 / $169.82
| Professional | | $123.03 | $138.04 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.49 / $151.36 / $154.88
| Professional | | $15.49 | $151.36 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $213.80
| Facility | | $158.49 | $158.49 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $177.83
| Professional | | $117.49 | $117.49 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $169.82 / $218.78
| Professional | | $165.96 | $169.82 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $7.94 / $77.62 / $123.03
| Facility | | $7.94 | $77.62 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $104.71 / $208.93
| Professional | | $77.62 | $104.71 | $208.93 |