- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Facility | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $112.20 / $154.88
| Professional | | $89.13 | $112.20 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $213.80 / $213.80
| Professional | | $158.49 | $213.80 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $630.96 / $1,202.26
| Facility | | $275.42 | $630.96 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $208.93 / $218.78
| Professional | | $199.53 | $208.93 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $138.04
| Facility | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $141.25 / $234.42
| Professional | | $102.33 | $141.25 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $398.11 / $446.68
| Facility | | $120.23 | $398.11 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $169.82 / $257.04
| Professional | | $107.15 | $169.82 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $151.36 / $208.93
| Professional | | $102.33 | $151.36 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $169.82 / $257.04
| Facility | | $72.44 | $169.82 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $97.72 / $147.91
| Professional | | $72.44 | $97.72 | $147.91 |