- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $158.49
| Facility | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $158.49 / $208.93
| Professional | | $91.20 | $158.49 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.50 / $194.98 / $380.19
| Facility | | $19.50 | $194.98 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $128.82 / $263.03
| Professional | | $21.88 | $128.82 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $181.97
| Facility | | $128.82 | $128.82 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $128.82 / $131.83
| Professional | | $109.65 | $128.82 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $23.44 / $91.20 / $204.17
| Facility | | $23.44 | $91.20 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $158.49 / $208.93
| Professional | | $77.62 | $158.49 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.75 / $114.82 / $154.88
| Professional | | $11.75 | $114.82 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $128.82
| Professional | | $123.03 | $123.03 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $177.83 / $223.87
| Professional | | $173.78 | $177.83 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9.33 / $93.33 / $128.82
| Facility | | $9.33 | $93.33 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $109.65 / $173.78
| Professional | | $79.43 | $109.65 | $173.78 |