- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $30.90
| Facility | | $30.90 | $30.90 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.13 / $28.18 / $30.90
| Professional | | $14.13 | $28.18 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $35.48 / $35.48 / $41.69
| Professional | | $35.48 | $35.48 | $41.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $117.49 / $162.18
| Facility | | $100.00 | $117.49 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.60 / $53.70 / $72.44
| Professional | | $16.60 | $53.70 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $27.54 / $31.62 / $37.15
| Facility | | $27.54 | $31.62 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $45.71 / $64.57
| Professional | | $33.88 | $45.71 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $27.54 / $33.88 / $57.54
| Facility | | $27.54 | $33.88 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $13.49 / $17.78 / $34.67
| Professional | | $13.49 | $17.78 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $50.12 / $70.79
| Professional | | $32.36 | $50.12 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $37.15 / $57.54
| Professional | | $28.18 | $37.15 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $57.54 / $102.33
| Professional | | $38.02 | $57.54 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $218.78
| Facility | | $75.86 | $75.86 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.60 / $169.82 / $398.11
| Professional | | $16.60 | $169.82 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.13 / $53.70 / $100.00
| Professional | | $14.13 | $53.70 | $100.00 |