- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $204.17 / $302.00
| Facility | | $104.71 | $204.17 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $199.53 / $467.74
| Professional | | $109.65 | $199.53 | $467.74 |
- 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
- $109.65 / $194.98 / $275.42
| Professional | | $109.65 | $194.98 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $281.84 / $426.58
| Professional | | $154.88 | $281.84 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $199.53 / $524.81
| Facility | | $120.23 | $199.53 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $295.12 / $1,096.48
| Professional | | $162.18 | $295.12 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $338.84 / $426.58
| Professional | | $245.47 | $338.84 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $323.59 / $446.68
| Professional | | $218.78 | $323.59 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $1,047.13 / $3,801.89
| Facility | | $199.53 | $1,047.13 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $223.87 / $354.81
| Professional | | $134.90 | $223.87 | $354.81 |