- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Facility | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $85.11 / $120.23
| Professional | | $61.66 | $85.11 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $117.49
| Professional | | $107.15 | $107.15 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $89.13 / $89.13
| Facility | | $61.66 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $104.71
| Professional | | $66.07 | $66.07 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $93.33 / $107.15
| Professional | | $85.11 | $93.33 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $125.89 / $204.17
| Facility | | $58.88 | $125.89 | $204.17 |
- 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
- $52.48 / $69.18 / $112.20
| Facility | | $52.48 | $69.18 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $69.18 / $104.71
| Professional | | $53.70 | $69.18 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,412.54 / $1,412.54
| Professional | | $1,412.54 | $1,412.54 | $1,412.54 |