- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $204.17 / $416.87
| Facility | | $123.03 | $204.17 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $123.03 / $173.78
| Professional | | $120.23 | $123.03 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $691.83 / $1,288.25
| Facility | | $275.42 | $691.83 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Professional | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $302.00 / $870.96
| Facility | | $144.54 | $302.00 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Professional | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $151.36 / $288.40
| Facility | | $123.03 | $151.36 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $123.03 / $194.98
| Professional | | $120.23 | $123.03 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Professional | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $177.83 / $407.38
| Facility | | $128.82 | $177.83 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Professional | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $218.78
| Facility | | $131.83 | $131.83 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | | $125.89 | $125.89 | $125.89 |