- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $141.25
| Facility | | $131.83 | $131.83 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $134.90 / $251.19
| Professional | | $107.15 | $134.90 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Professional | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $309.03 / $309.03
| Facility | | $79.43 | $309.03 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Facility | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $194.98
| Professional | | $141.25 | $141.25 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $2,238.72 / $2,238.72
| Professional | | $1,698.24 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $223.87 / $371.54
| Facility | | $117.49 | $223.87 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $134.90 / $288.40
| Professional | | $112.20 | $134.90 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Professional | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $223.87 / $371.54
| Facility | | $117.49 | $223.87 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $194.98
| Professional | | $141.25 | $141.25 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $173.78 / $263.03
| Facility | | $102.33 | $173.78 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $138.04 / $173.78
| Professional | | $93.33 | $138.04 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $309.03 / $309.03
| Professional | | $134.90 | $309.03 | $309.03 |