- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $316.23 / $1,000.00
| Facility | | $204.17 | $316.23 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $144.54 / $331.13
| Professional | | $100.00 | $144.54 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $251.19 / $338.84
| Facility | | $169.82 | $251.19 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $169.82 / $223.87
| Professional | | $144.54 | $169.82 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $338.84 / $446.68
| Facility | | $60.26 | $338.84 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $177.83 / $234.42
| Professional | | $85.11 | $177.83 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $213.80 / $575.44
| Facility | | $169.82 | $213.80 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $213.80 / $489.78
| Professional | | $169.82 | $213.80 | $489.78 |
- 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
- $169.82 / $169.82 / $338.84
| Facility | | $169.82 | $169.82 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $204.17
| Professional | | $169.82 | $169.82 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $269.15 / $524.81
| Facility | | $169.82 | $269.15 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $204.17
| Professional | | $151.36 | $151.36 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $257.04 / $446.68
| Facility | | $194.98 | $257.04 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $169.82 / $223.87
| Professional | | $144.54 | $169.82 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $204.17 / $204.17
| Facility | | $169.82 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $70.79 / $190.55
| Professional | | $53.70 | $70.79 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $169.82 / $309.03
| Professional | | $75.86 | $169.82 | $309.03 |