- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $363.08 / $831.76
| Facility | | $169.82 | $363.08 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $141.25 / $478.63
| Professional | | $93.33 | $141.25 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $416.87
| Facility | | $234.42 | $234.42 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $158.49 / $257.04
| Professional | | $77.62 | $158.49 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $309.03 / $371.54
| Professional | | $158.49 | $309.03 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $263.03 / $794.33
| Facility | | $141.25 | $263.03 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $169.82 / $223.87
| Professional | | $141.25 | $169.82 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $288.40
| Facility | | $141.25 | $141.25 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $251.19
| Professional | | $141.25 | $141.25 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $204.17 / $416.87
| Facility | | $141.25 | $204.17 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $158.49 / $213.80
| Professional | | $141.25 | $158.49 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $363.08 / $562.34
| Facility | | $213.80 | $363.08 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $120.23 / $169.82
| Professional | | $112.20 | $120.23 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $213.80 / $229.09
| Facility | | $169.82 | $213.80 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $95.50 / $165.96
| Professional | | $85.11 | $95.50 | $165.96 |