- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Facility | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $147.91 / $173.78
| Professional | | $138.04 | $147.91 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $245.47
| Professional | | $138.04 | $138.04 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $30.90
| Professional | | $30.90 | $30.90 | $30.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $288.40 / $371.54
| Facility | | $169.82 | $288.40 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $154.88 / $173.78
| Professional | | $138.04 | $154.88 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $169.82 / $234.42
| Facility | | $144.54 | $169.82 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $173.78 / $173.78
| Professional | | $165.96 | $173.78 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $165.96 / $213.80
| Facility | | $138.04 | $165.96 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $165.96 / $213.80
| Professional | | $138.04 | $165.96 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $288.40 / $371.54
| Facility | | $173.78 | $288.40 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $151.36
| Professional | | $144.54 | $144.54 | $151.36 |