- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $141.25
| Facility | | $128.82 | $128.82 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $131.83 / $245.47
| Professional | | $100.00 | $131.83 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $302.00 / $302.00
| Facility | | $79.43 | $302.00 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Facility | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $158.49
| Professional | | $117.49 | $117.49 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,174.90
| Facility | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,698.24 / $1,698.24
| Professional | | $1,513.56 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $223.87 / $371.54
| Facility | | $112.20 | $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
- $144.54 / $147.91 / $147.91
| Professional | | $144.54 | $147.91 | $147.91 |
- 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
- $117.49 / $117.49 / $158.49
| Professional | | $117.49 | $117.49 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $173.78 / $257.04
| Facility | | $100.00 | $173.78 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $138.04 / $169.82
| Professional | | $93.33 | $138.04 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $302.00 / $302.00
| Professional | | $134.90 | $302.00 | $302.00 |