- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $131.83 / $354.81
| Professional | | $104.71 | $131.83 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $173.78 / $288.40
| Professional | | $125.89 | $173.78 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $151.36 / $269.15
| Professional | | $144.54 | $151.36 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $162.18 / $269.15
| Professional | | $125.89 | $162.18 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $131.83 / $239.88
| Professional | | $109.65 | $131.83 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $177.83 / $245.47
| Professional | | $144.54 | $177.83 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $165.96 / $263.03
| Facility | | $114.82 | $165.96 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $794.33
| Professional | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $162.18 / $257.04
| Facility | | $134.90 | $162.18 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $162.18 / $257.04
| Professional | | $134.90 | $162.18 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $154.88 / $245.47
| Professional | | $109.65 | $154.88 | $245.47 |