- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $245.47 / $245.47
| Facility | | $158.49 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $162.18 / $245.47
| Professional | | $97.72 | $162.18 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $275.42
| Facility | | $257.04 | $257.04 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $426.58
| Professional | | $251.19 | $251.19 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $416.87
| Facility | | $141.25 | $141.25 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $309.03 / $389.05
| Professional | | $229.09 | $309.03 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $257.04
| Professional | | $257.04 | $257.04 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $169.82 / $269.15
| Facility | | $138.04 | $169.82 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $131.83
| Professional | | $95.50 | $95.50 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $257.04 / $10,000.00
| Facility | | $147.91 | $257.04 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $257.04 / $10,000.00
| Professional | | $147.91 | $257.04 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $263.03 / $263.03
| Facility | | $208.93 | $263.03 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $208.93 / $354.81
| Professional | | $128.82 | $208.93 | $354.81 |