- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Facility | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $120.23 / $162.18
| Professional | | $69.18 | $120.23 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $199.53 / $257.04
| Facility | | $141.25 | $199.53 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $169.82 / $169.82
| Professional | | $162.18 | $169.82 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $102.33
| Facility | | $93.33 | $93.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $93.33 / $112.20
| Professional | | $79.43 | $93.33 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $89.13 / $162.18
| Facility | | $48.98 | $89.13 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $128.82 / $147.91
| Professional | | $123.03 | $128.82 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.48 / $112.20 / $114.82
| Professional | | $11.48 | $112.20 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $208.93 / $239.88
| Facility | | $141.25 | $208.93 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $109.65
| Professional | | $102.33 | $102.33 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $147.91 / $162.18
| Professional | | $125.89 | $147.91 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6.31 / $54.95 / $100.00
| Facility | | $6.31 | $54.95 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $74.13 / $109.65
| Professional | | $63.10 | $74.13 | $109.65 |