- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $104.71 / $104.71
| Facility | | $95.50 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $104.71 / $204.17
| Professional | | $81.28 | $104.71 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $389.05 / $812.83
| Facility | | $288.40 | $389.05 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $177.83 / $190.55
| Professional | | $173.78 | $177.83 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $218.78 / $295.12
| Professional | | $77.62 | $218.78 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $186.21 / $446.68
| Facility | | $104.71 | $186.21 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $173.78 / $741.31
| Professional | | $112.20 | $173.78 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $234.42 / $331.13
| Professional | | $190.55 | $234.42 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $194.98 / $331.13
| Professional | | $177.83 | $194.98 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $74.13 / $162.18
| Professional | | $26.30 | $74.13 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $436.52 / $691.83
| Facility | | $83.18 | $436.52 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $173.78 / $245.47
| Professional | | $109.65 | $173.78 | $245.47 |