- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $190.55 / $371.54
| Facility | | $91.20 | $190.55 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $162.18 / $562.34
| Professional | | $91.20 | $162.18 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $891.25 / $1,737.80
| Facility | | $676.08 | $891.25 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $186.21 / $302.00
| Professional | | $114.82 | $186.21 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $190.55
| Facility | | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $295.12 / $489.78
| Professional | | $169.82 | $295.12 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $239.88 / $478.63
| Facility | | $114.82 | $239.88 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $295.12 / $1,230.27
| Professional | | $173.78 | $295.12 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $316.23 / $457.09
| Professional | | $229.09 | $316.23 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $190.55
| Facility | | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $316.23 / $489.78
| Professional | | $194.98 | $316.23 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $1,047.13 / $3,801.89
| Facility | | $346.74 | $1,047.13 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $213.80 / $371.54
| Professional | | $123.03 | $213.80 | $371.54 |