- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $269.15 / $707.95
| Facility | | $107.15 | $269.15 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $204.17 / $269.15
| Professional | | $138.04 | $204.17 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $309.03
| Facility | | $257.04 | $257.04 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $251.19
| Professional | | $234.42 | $234.42 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $218.78 / $229.09
| Facility | | $138.04 | $218.78 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $245.47
| Professional | | $158.49 | $158.49 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $154.88 / $208.93
| Professional | | $144.54 | $154.88 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $269.15 / $457.09
| Facility | | $128.82 | $269.15 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $154.88 / $251.19
| Facility | | $117.49 | $154.88 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $154.88 / $234.42
| Professional | | $120.23 | $154.88 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $2,238.72 / $2,344.23
| Professional | | $2,238.72 | $2,238.72 | $2,344.23 |