- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $123.03
| Professional | | $112.20 | $112.20 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9.12 / $12.30 / $33.88
| Facility | | $9.12 | $12.30 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.13 / $8.13 / $8.13
| Professional | | $8.13 | $8.13 | $8.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $120.23 / $125.89
| Facility | | $112.20 | $120.23 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $316.23 / $851.14
| Facility | | $144.54 | $316.23 | $851.14 |
- 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
- $933.25 / $933.25 / $933.25
| Facility | | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,288.25 / $1,288.25
| Professional | | $1,230.27 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $114.82 / $316.23
| Facility | | $112.20 | $114.82 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $120.23 / $229.09
| Professional | | $112.20 | $120.23 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $354.81
| Professional | | $32.36 | $33.11 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $524.81 / $524.81
| Professional | | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $117.49 / $398.11
| Facility | | $112.20 | $117.49 | $398.11 |
- 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
- $102.33 / $316.23 / $549.54
| Facility | | $102.33 | $316.23 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $331.13
| Professional | | $125.89 | $125.89 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $125.89 / $125.89
| Professional | | $109.65 | $125.89 | $125.89 |