- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $104.71 / $186.21
| Professional | | $75.86 | $104.71 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $83.18
| Professional | | $83.18 | $83.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $389.05 / $467.74
| Professional | | $134.90 | $389.05 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $131.83 / $190.55
| Facility | | $107.15 | $131.83 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $141.25 / $190.55
| Professional | | $128.82 | $141.25 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $169.82 / $194.98
| Facility | | $141.25 | $169.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $177.83 / $218.78
| Professional | | $141.25 | $177.83 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $151.36 / $223.87
| Facility | | $107.15 | $151.36 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $154.88 / $186.21
| Professional | | $79.43 | $154.88 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $281.84 / $691.83
| Facility | | $147.91 | $281.84 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $199.53 / $199.53
| Professional | | $177.83 | $199.53 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $131.83 / $288.40
| Facility | | $75.86 | $131.83 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $87.10 / $165.96
| Professional | | $69.18 | $87.10 | $165.96 |