- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Facility | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $173.78 / $295.12
| Professional | | $151.36 | $173.78 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $575.44
| Facility | | $346.74 | $346.74 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $323.59 / $389.05
| Professional | | $295.12 | $323.59 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $794.33 / $1,698.24
| Facility | | $218.78 | $794.33 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $489.78 / $660.69
| Professional | | $162.18 | $489.78 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $281.84 / $426.58
| Facility | | $173.78 | $281.84 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $478.63 / $616.60
| Professional | | $309.03 | $478.63 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $338.84 / $1,737.80
| Facility | | $173.78 | $338.84 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $229.09 / $398.11
| Professional | | $158.49 | $229.09 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $229.09
| Professional | | $54.95 | $70.79 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $389.05 / $676.08
| Professional | | $245.47 | $389.05 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $524.81 / $1,000.00
| Professional | | $346.74 | $524.81 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $691.83 / $1,995.26
| Facility | | $218.78 | $691.83 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $323.59 / $2,041.74
| Professional | | $162.18 | $323.59 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $239.88 / $346.74
| Facility | | $190.55 | $239.88 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $169.82 / $295.12
| Professional | | $131.83 | $169.82 | $295.12 |