- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $144.54 / $575.44
| Facility | | $120.23 | $144.54 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $602.56 / $616.60
| Professional | | $562.34 | $602.56 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $691.83 / $1,000.00
| Professional | | $660.69 | $691.83 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $165.96 / $1,148.15
| Facility | | $138.04 | $165.96 | $1,148.15 |
- 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 / $933.25
| Facility | | $151.36 | $537.03 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $524.81 / $616.60
| Professional | | $158.49 | $524.81 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $758.58 / $758.58
| Facility | | $616.60 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $758.58
| Professional | | $616.60 | $616.60 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $50,118.72 / $75,857.76
| Facility | | $1,318.26 | $50,118.72 | $75,857.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $524.81 / $724.44
| Professional | | $125.89 | $524.81 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $758.58 / $758.58
| Facility | | $616.60 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $758.58
| Professional | | $616.60 | $616.60 | $758.58 |