- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $707.95 / $707.95
| Facility | | $120.23 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $776.25
| Professional | | $707.95 | $707.95 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $1,000.00
| Professional | | $707.95 | $707.95 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $165.96 / $1,479.11
| Facility | | $138.04 | $165.96 | $1,479.11 |
- 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 / $537.03 / $2,041.74
| Facility | | $151.36 | $537.03 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $1,148.15 / $1,348.96
| Professional | | $158.49 | $1,148.15 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,000.00 / $1,000.00
| Facility | | $977.24 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $977.24 / $1,000.00
| Professional | | $977.24 | $977.24 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $50,118.72 / $75,857.76
| Facility | | $1,202.26 | $50,118.72 | $75,857.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $1,778.28
| Professional | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,230.27
| Facility | | $1,071.52 | $1,071.52 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $977.24 / $1,905.46
| Professional | | $125.89 | $977.24 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,000.00 / $1,000.00
| Facility | | $977.24 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $977.24 / $1,000.00
| Professional | | $977.24 | $977.24 | $1,000.00 |