- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $162.18
| Facility | | $151.36 | $151.36 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $158.49 / $288.40
| Professional | | $114.82 | $158.49 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $354.81 / $354.81
| Facility | | $79.43 | $354.81 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Facility | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $162.18
| Professional | | $117.49 | $117.49 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,348.96 / $1,348.96
| Facility | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,949.84 / $1,949.84
| Professional | | $1,737.80 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $257.04 / $416.87
| Facility | | $117.49 | $257.04 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $162.18 / $331.13
| Professional | | $120.23 | $162.18 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $173.78 / $173.78
| Professional | | $162.18 | $173.78 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $257.04 / $407.38
| Facility | | $128.82 | $257.04 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $162.18
| Professional | | $117.49 | $117.49 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $199.53 / $302.00
| Facility | | $117.49 | $199.53 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $158.49 / $199.53
| Professional | | $107.15 | $158.49 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $354.81 / $354.81
| Professional | | $154.88 | $354.81 | $354.81 |