- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Facility | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $194.98 / $234.42
| Professional | | $120.23 | $194.98 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.05 / $190.55 / $346.74
| Facility | | $19.05 | $190.55 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.91 / $158.49 / $263.03
| Professional | | $22.91 | $158.49 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $162.18
| Facility | | $154.88 | $154.88 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.62 / $131.83 / $154.88
| Professional | | $18.62 | $131.83 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $117.49 / $194.98
| Facility | | $25.12 | $117.49 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $194.98 / $234.42
| Professional | | $120.23 | $194.98 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.48 / $112.20 / $154.88
| Professional | | $11.48 | $112.20 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $158.49
| Professional | | $151.36 | $151.36 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $218.78 / $218.78
| Professional | | $162.18 | $218.78 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $8.51 / $74.13 / $165.96
| Facility | | $8.51 | $74.13 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $97.72 / $165.96
| Professional | | $85.11 | $97.72 | $165.96 |