- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Facility | | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $57.54 / $213.80
| Professional | | $37.15 | $57.54 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $37.15 / $79.43
| Professional | | $28.84 | $37.15 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $79.43 / $151.36
| Professional | | $57.54 | $79.43 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $79.43 / $104.71
| Professional | | $57.54 | $79.43 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $57.54 / $57.54
| Facility | | $48.98 | $57.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $45.71 / $131.83
| Professional | | $31.62 | $45.71 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $389.05
| Facility | | $389.05 | $389.05 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $1,000.00
| Professional | | $489.78 | $489.78 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $77.62 / $144.54
| Facility | | $47.86 | $77.62 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $79.43 / $151.36
| Professional | | $37.15 | $79.43 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $57.54
| Professional | | $32.36 | $33.11 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $102.33 / $128.82
| Professional | | $57.54 | $102.33 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $77.62 / $144.54
| Facility | | $46.77 | $77.62 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $48.98 / $141.25
| Professional | | $29.51 | $48.98 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $60.26
| Facility | | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $56.23 / $131.83
| Professional | | $39.81 | $56.23 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $30.20 / $58.88
| Professional | | $25.70 | $30.20 | $58.88 |