- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Facility | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $169.82 / $223.87
| Professional | | $104.71 | $169.82 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $213.80 / $363.08
| Facility | | $190.55 | $213.80 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $245.47 / $263.03
| Professional | | $229.09 | $245.47 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $138.04
| Facility | | $131.83 | $131.83 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $131.83 / $204.17
| Professional | | $112.20 | $131.83 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $22.91 / $169.82 / $229.09
| Facility | | $22.91 | $169.82 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $190.55 / $199.53
| Professional | | $186.21 | $190.55 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.30 / $120.23 / $162.18
| Professional | | $12.30 | $120.23 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $288.40 / $331.13
| Facility | | $190.55 | $288.40 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $147.91
| Professional | | $141.25 | $141.25 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $199.53 / $229.09
| Professional | | $186.21 | $199.53 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $8.91 / $83.18 / $141.25
| Facility | | $8.91 | $83.18 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $104.71 / $158.49
| Professional | | $95.50 | $104.71 | $158.49 |