- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Facility | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $102.33 / $169.82
| Professional | | $77.62 | $102.33 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $338.84
| Facility | | $204.17 | $204.17 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $229.09
| Professional | | $190.55 | $190.55 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $478.63 / $1,023.29
| Facility | | $112.20 | $478.63 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $295.12 / $389.05
| Professional | | $83.18 | $295.12 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $165.96 / $257.04
| Facility | | $102.33 | $165.96 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $295.12 / $371.54
| Professional | | $181.97 | $295.12 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $204.17 / $933.25
| Facility | | $102.33 | $204.17 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $104.71 / $223.87
| Professional | | $89.13 | $104.71 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $114.82
| Professional | | $54.95 | $70.79 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Facility | | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $234.42 / $407.38
| Professional | | $144.54 | $234.42 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $309.03 / $562.34
| Professional | | $204.17 | $309.03 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $407.38 / $933.25
| Facility | | $112.20 | $407.38 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $165.96 / $1,000.00
| Professional | | $83.18 | $165.96 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $104.71 / $204.17
| Facility | | $69.18 | $104.71 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $100.00 / $194.98
| Professional | | $74.13 | $100.00 | $194.98 |