- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $125.89
| Facility | | $114.82 | $114.82 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $134.90 / $234.42
| Professional | | $114.82 | $134.90 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $194.98 / $239.88
| Professional | | $158.49 | $194.98 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $269.15 / $269.15
| Facility | | $79.43 | $269.15 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $173.78
| Facility | | $165.96 | $165.96 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $165.96
| Professional | | $120.23 | $120.23 | $165.96 |
- 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
- $1,778.28 / $2,187.76 / $2,187.76
| Professional | | $1,778.28 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $223.87 / $389.05
| Facility | | $117.49 | $223.87 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $147.91 / $295.12
| Professional | | $114.82 | $147.91 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $138.04
| Professional | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $218.78 / $389.05
| Facility | | $125.89 | $218.78 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $165.96
| Professional | | $120.23 | $120.23 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $204.17 / $309.03
| Facility | | $120.23 | $204.17 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $204.17
| Professional | | $109.65 | $162.18 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $269.15 / $269.15
| Professional | | $162.18 | $269.15 | $269.15 |