- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $346.74 / $1,288.25
| Facility | | $125.89 | $346.74 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $107.15 / $457.09
| Professional | | $100.00 | $107.15 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $151.36
| Facility | | $107.15 | $107.15 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $204.17 / $5,011.87
| Facility | | $173.78 | $204.17 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $380.19 / $407.38
| Facility | | $107.15 | $380.19 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Professional | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $141.25 / $141.25
| Professional | | $117.49 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $39.81 / $53.70
| Professional | | $39.81 | $39.81 | $53.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $120.23 / $426.58
| Facility | | $87.10 | $120.23 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $125.89
| Facility | | $107.15 | $107.15 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $114.82 / $323.59
| Facility | | $107.15 | $114.82 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $107.15 / $123.03
| Professional | | $100.00 | $107.15 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $281.84 / $338.84
| Professional | | $0.60 | $281.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $141.25
| Professional | | $63.10 | $63.10 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $128.82
| Professional | | $107.15 | $107.15 | $128.82 |