- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $131.83
| Facility | | $125.89 | $125.89 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $134.90 / $199.53
| Professional | | $117.49 | $134.90 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $134.90
| Professional | | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $229.09 / $288.40
| Professional | | $177.83 | $229.09 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $288.40 / $288.40
| Facility | | $79.43 | $288.40 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $186.21 / $186.21
| Facility | | $186.21 | $186.21 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $186.21
| Professional | | $134.90 | $134.90 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $2,511.89 / $2,511.89
| Professional | | $1,698.24 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $223.87 / $380.19
| Facility | | $120.23 | $223.87 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $134.90 / $295.12
| Professional | | $120.23 | $134.90 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $158.49
| Professional | | $154.88 | $154.88 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $213.80 / $380.19
| Facility | | $120.23 | $213.80 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $186.21
| Professional | | $134.90 | $134.90 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $177.83 / $288.40
| Facility | | $95.50 | $177.83 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $151.36 / $177.83
| Professional | | $104.71 | $151.36 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $288.40 / $288.40
| Professional | | $147.91 | $288.40 | $288.40 |