- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $251.19 / $707.95
| Facility | | $60.26 | $251.19 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $151.36 / $316.23
| Professional | | $112.20 | $151.36 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $114.82
| Professional | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $186.21 / $218.78
| Facility | | $162.18 | $186.21 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $186.21 / $186.21
| Professional | | $120.23 | $186.21 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $141.25 / $758.58
| Facility | | $95.50 | $141.25 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $144.54 / $323.59
| Professional | | $91.20 | $144.54 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $158.49
| Professional | | $112.20 | $112.20 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $151.36 / $165.96
| Professional | | $112.20 | $151.36 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $165.96 / $186.21
| Facility | | $77.62 | $165.96 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $77.62 / $245.47
| Professional | | $64.57 | $77.62 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $186.21 / $186.21
| Professional | | $112.20 | $186.21 | $186.21 |