- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $239.88 / $281.84
| Professional | | $97.72 | $239.88 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $616.60
| Facility | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $263.03 / $354.81
| Professional | | $169.82 | $263.03 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $831.76 / $1,202.26
| Professional | | $354.81 | $831.76 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Professional | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $354.81 / $407.38
| Professional | | $323.59 | $354.81 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $295.12 / $371.54
| Professional | | $263.03 | $295.12 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,778.28 / $1,778.28
| Professional | | $1,621.81 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $263.03 / $323.59
| Facility | | $138.04 | $263.03 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Professional | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $602.56 / $602.56
| Professional | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $263.03
| Professional | | $177.83 | $177.83 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Facility | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $120.23 / $281.84
| Professional | | $100.00 | $120.23 | $281.84 |