- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Facility | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $158.49 / $251.19
| Professional | | $112.20 | $158.49 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $275.42 / $602.56
| Facility | | $177.83 | $275.42 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $309.03 / $380.19
| Professional | | $295.12 | $309.03 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $281.84
| Facility | | $125.89 | $125.89 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $125.89 / $229.09
| Professional | | $107.15 | $125.89 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $251.19 / $363.08
| Facility | | $36.31 | $251.19 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $169.82 / $186.21
| Professional | | $162.18 | $169.82 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $204.17 / $208.93
| Professional | | $20.89 | $204.17 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $263.03 / $371.54
| Facility | | $177.83 | $263.03 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $134.90
| Professional | | $128.82 | $128.82 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $186.21 / $295.12
| Professional | | $186.21 | $186.21 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12.88 / $100.00 / $199.53
| Facility | | $12.88 | $100.00 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $169.82 / $263.03
| Professional | | $112.20 | $169.82 | $263.03 |