- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $128.82 / $128.82
| Facility | | $117.49 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $128.82 / $213.80
| Professional | | $102.33 | $128.82 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $1,905.46 / $4,466.84
| Facility | | $645.65 | $1,905.46 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $257.04 / $416.87
| Professional | | $173.78 | $257.04 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $257.04 / $380.19 / $630.96
| Professional | 50 | $257.04 | $380.19 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $457.09 / $1,096.48
| Facility | | $323.59 | $457.09 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $338.84 / $537.03
| Professional | | $204.17 | $338.84 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $436.52 / $851.14
| Facility | | $346.74 | $436.52 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $302.00 / $489.78
| Professional | | $204.17 | $302.00 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $218.78 / $380.19
| Facility | | $128.82 | $218.78 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $223.87 / $831.76
| Professional | | $120.23 | $223.87 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $3,715.35 / $5,754.40
| Facility | | $2,570.40 | $3,715.35 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $213.80 / $436.52
| Professional | | $123.03 | $213.80 | $436.52 |