- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Facility | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $87.10 / $446.68
| Professional | | $30.20 | $87.10 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $102.33 / $102.33
| Professional | | $93.33 | $102.33 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Facility | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $123.03 / $223.87
| Professional | | $46.77 | $123.03 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $147.91 / $457.09
| Facility | | $85.11 | $147.91 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $35.48 / $52.48 / $104.71
| Professional | | $35.48 | $52.48 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $117.49 / $281.84
| Professional | | $114.82 | $117.49 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Facility | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $263.03 / $281.84
| Professional | | $147.91 | $263.03 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $53.70 / $74.13
| Facility | | $33.11 | $53.70 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $52.48 / $83.18
| Professional | | $36.31 | $52.48 | $83.18 |