- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $100.00 / $117.49
| Professional | | $83.18 | $100.00 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Facility | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $134.90
| Professional | | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Professional | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $125.89
| Facility | | $112.20 | $112.20 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $128.82
| Professional | | $95.50 | $95.50 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $141.25 / $194.98
| Professional | | $123.03 | $141.25 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $97.72 / $186.21
| Facility | | $57.54 | $97.72 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10.47 / $93.33 / $165.96
| Facility | | $10.47 | $93.33 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.47 / $69.18 / $158.49
| Professional | | $10.47 | $69.18 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $7.59 / $60.26 / $117.49
| Facility | | $7.59 | $60.26 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $89.13 / $141.25
| Professional | | $79.43 | $89.13 | $141.25 |