- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Facility | | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $54.95 / $100.00
| Professional | | $30.20 | $54.95 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $239.88 / $309.03
| Facility | | $47.86 | $239.88 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $165.96 / $275.42
| Professional | | $102.33 | $165.96 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $426.58 / $512.86
| Professional | | $213.80 | $426.58 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $112.20 / $288.40
| Facility | | $63.10 | $112.20 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $61.66 / $151.36
| Professional | | $32.36 | $61.66 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $89.13 / $134.90
| Facility | | $47.86 | $89.13 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $48.98 / $89.13
| Professional | | $33.11 | $48.98 | $89.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $112.20 / $288.40
| Facility | | $63.10 | $112.20 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $128.82 / $257.04
| Professional | | $70.79 | $128.82 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $281.84 / $363.08
| Facility | | $204.17 | $281.84 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $165.96 / $295.12
| Professional | | $85.11 | $165.96 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $323.59 / $426.58
| Facility | | $263.03 | $323.59 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $67.61
| Professional | | $67.61 | $67.61 | $67.61 |