- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Facility | | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $100.00
| Professional | | $91.20 | $91.20 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $154.88 / $154.88
| Professional | | $134.90 | $154.88 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $165.96 / $288.40
| Facility | | $87.10 | $165.96 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $125.89 / $223.87
| Professional | | $69.18 | $125.89 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $93.33 / $204.17
| Facility | | $91.20 | $93.33 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $75.86
| Professional | | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $69.18 / $204.17
| Facility | | $67.61 | $69.18 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $213.80
| Professional | | $67.61 | $67.61 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $54.95 / $70.79
| Professional | | $32.36 | $54.95 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $72.44
| Facility | | $67.61 | $67.61 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $72.44 / $117.49
| Professional | | $70.79 | $72.44 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $223.87 / $446.68
| Professional | | $141.25 | $223.87 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $134.90 / $302.00
| Facility | | $91.20 | $134.90 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $389.05
| Professional | | $91.20 | $91.20 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $151.36
| Professional | | $123.03 | $123.03 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $69.18 / $162.18
| Facility | | $69.18 | $69.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $125.89 / $144.54
| Professional | | $69.18 | $125.89 | $144.54 |