- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $77.62
| Facility | | $77.62 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $77.62 / $97.72
| Professional | | $57.54 | $77.62 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $123.03
| Professional | | $100.00 | $100.00 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Professional | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $117.49
| Facility | | $81.28 | $81.28 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $69.18 / $107.15
| Professional | | $69.18 | $69.18 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $97.72 / $138.04
| Professional | | $87.10 | $97.72 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Professional | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $77.62 / $186.21
| Facility | | $57.54 | $77.62 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $8.71 / $72.44 / $177.83
| Facility | | $8.71 | $72.44 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.32 / $58.88 / $177.83
| Professional | | $8.32 | $58.88 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6.92 / $57.54 / $97.72
| Facility | | $6.92 | $57.54 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $77.62 / $123.03
| Professional | | $66.07 | $77.62 | $123.03 |