- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $204.17 / $204.17
| Facility | | $91.20 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $104.71 / $204.17
| Professional | | $91.20 | $104.71 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $302.00 / $588.84
| Facility | | $229.09 | $302.00 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $144.54 / $194.98
| Professional | | $85.11 | $144.54 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Facility | | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $147.91 / $223.87
| Professional | | $104.71 | $147.91 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $144.54 / $229.09
| Facility | | $81.28 | $144.54 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $199.53 / $616.60
| Professional | | $104.71 | $199.53 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $204.17 / $239.88
| Professional | | $162.18 | $204.17 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $162.18 / $218.78
| Professional | | $134.90 | $162.18 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $87.10 / $112.20
| Facility | | $77.62 | $87.10 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $177.83 / $251.19
| Professional | | $104.71 | $177.83 | $251.19 |