- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Facility | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $87.10 / $109.65
| Professional | | $63.10 | $87.10 | $109.65 |
- 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
- $74.13 / $74.13 / $74.13
| Professional | | $74.13 | $74.13 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $323.59 / $389.05
| Professional | | $112.20 | $323.59 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $158.49
| Facility | | $87.10 | $109.65 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $117.49 / $162.18
| Professional | | $107.15 | $117.49 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $141.25 / $144.54
| Facility | | $114.82 | $141.25 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $158.49
| Professional | | $144.54 | $144.54 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $125.89 / $181.97
| Facility | | $83.18 | $125.89 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $125.89 / $154.88
| Professional | | $74.13 | $125.89 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $229.09 / $575.44
| Facility | | $120.23 | $229.09 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $162.18 / $162.18
| Professional | | $147.91 | $162.18 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $81.28 / $234.42
| Facility | | $67.61 | $81.28 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $72.44 / $138.04
| Professional | | $56.23 | $72.44 | $138.04 |