- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $281.84 / $363.08
| Facility | | $204.17 | $281.84 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $162.18 / $229.09
| Professional | | $125.89 | $162.18 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $416.87 / $831.76
| Facility | | $389.05 | $416.87 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $223.87 / $512.86
| Professional | | $173.78 | $223.87 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $263.03 / $371.54
| Facility | | $154.88 | $263.03 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $275.42 / $416.87
| Professional | | $199.53 | $275.42 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $234.42
| Facility | | $223.87 | $223.87 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $223.87
| Professional | | $165.96 | $165.96 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $223.87
| Professional | | $165.96 | $165.96 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $234.42 / $338.84
| Professional | | $165.96 | $234.42 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $467.74
| Facility | | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $436.52 / $812.83
| Professional | | $371.54 | $436.52 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $239.88 / $389.05
| Facility | | $114.82 | $239.88 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $173.78 / $245.47
| Professional | | $109.65 | $173.78 | $245.47 |