- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $125.89 / $263.03
| Professional | | $107.15 | $125.89 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $151.36 / $234.42
| Professional | | $114.82 | $151.36 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $147.91 / $269.15
| Professional | | $131.83 | $147.91 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $147.91 / $245.47
| Professional | | $117.49 | $147.91 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $125.89 / $199.53
| Professional | | $102.33 | $125.89 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $173.78 / $223.87
| Professional | | $141.25 | $173.78 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $154.88 / $251.19
| Facility | | $112.20 | $154.88 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $263.03
| Professional | | $223.87 | $223.87 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $147.91 / $229.09
| Facility | | $123.03 | $147.91 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $147.91 / $229.09
| Professional | | $123.03 | $147.91 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Facility | | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $138.04 / $223.87
| Professional | | $95.50 | $138.04 | $223.87 |