- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $263.03
| Facility | | $123.03 | $123.03 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $181.97 / $269.15
| Professional | | $125.89 | $181.97 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $245.47
| Professional | | $229.09 | $229.09 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Facility | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $186.21
| Professional | | $128.82 | $128.82 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $147.91 / $194.98
| Professional | | $138.04 | $147.91 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $263.03 / $436.52
| Facility | | $123.03 | $263.03 | $436.52 |
- 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
- $89.13 / $131.83 / $245.47
| Facility | | $89.13 | $131.83 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $147.91 / $208.93
| Professional | | $109.65 | $147.91 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,412.54 / $1,412.54
| Facility | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,513.56 / $2,187.76
| Professional | | $1,513.56 | $1,513.56 | $2,187.76 |