- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $323.59 / $1,000.00
| Facility | | $128.82 | $323.59 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $154.88 / $234.42
| Professional | | $114.82 | $154.88 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $2,630.27 / $4,073.80
| Facility | | $891.25 | $2,630.27 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Facility | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $398.11 / $851.14
| Facility | | $125.89 | $398.11 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $123.03 / $302.00
| Professional | | $87.10 | $123.03 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,445.44 / $1,445.44
| Professional | | $954.99 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $194.98 / $363.08
| Facility | | $134.90 | $194.98 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $165.96 / $288.40
| Professional | | $102.33 | $165.96 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $208.93 / $407.38
| Professional | | $194.98 | $208.93 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $194.98 / $537.03
| Facility | | $131.83 | $194.98 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $151.36 / $302.00
| Professional | | $87.10 | $151.36 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $194.98 / $234.42
| Facility | | $81.28 | $194.98 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $194.98
| Professional | | $81.28 | $81.28 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $131.83 / $194.98
| Professional | | $75.86 | $131.83 | $194.98 |