- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $144.54 / $1,174.90
| Facility | | $120.23 | $144.54 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $1,174.90 / $1,258.93
| Professional | | $562.34 | $1,174.90 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $1,174.90 / $1,174.90
| Professional | | $177.83 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $165.96 / $1,819.70
| Facility | | $114.82 | $165.96 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $144.54
| Professional | | $125.89 | $125.89 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $457.09 / $691.83
| Facility | | $151.36 | $457.09 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $389.05 / $457.09
| Professional | | $158.49 | $389.05 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,230.27
| Facility | | $1,174.90 | $1,174.90 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,230.27 / $1,230.27
| Professional | | $1,174.90 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $50,118.72 / $75,857.76
| Facility | | $281.84 | $50,118.72 | $75,857.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,258.93 / $1,258.93
| Professional | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $389.05 / $1,548.82
| Professional | | $125.89 | $389.05 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,288.25
| Facility | | $1,174.90 | $1,174.90 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,230.27 / $1,230.27
| Professional | | $1,174.90 | $1,230.27 | $1,230.27 |