- 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
- $114.82 / $190.55 / $257.04
| Professional | | $114.82 | $190.55 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $239.88 / $478.63
| Facility | | $23.99 | $239.88 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.92 / $162.18 / $281.84
| Professional | | $26.92 | $162.18 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $218.78
| Facility | | $123.03 | $123.03 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $104.71 / $128.82
| Professional | | $16.98 | $104.71 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $114.82 / $194.98
| Facility | | $28.18 | $114.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $190.55 / $257.04
| Professional | | $114.82 | $190.55 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.13 / $141.25 / $190.55
| Professional | | $14.13 | $141.25 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $162.18
| Professional | | $154.88 | $154.88 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $223.87 / $269.15
| Professional | | $218.78 | $223.87 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $11.48 / $114.82 / $154.88
| Facility | | $11.48 | $114.82 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $131.83 / $208.93
| Professional | | $97.72 | $131.83 | $208.93 |