- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $229.09 / $537.03
| Facility | | $112.20 | $229.09 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $128.82 / $457.09
| Professional | | $107.15 | $128.82 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Professional | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $288.40 / $2,884.03
| Facility | | $114.82 | $288.40 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $288.40 / $724.44
| Professional | | $128.82 | $288.40 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $851.14
| Professional | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $213.80 / $645.65
| Facility | | $114.82 | $213.80 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $371.54 / $1,000.00
| Professional | | $257.04 | $371.54 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $741.31 / $2,884.03
| Facility | | $75.86 | $741.31 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $229.09 / $512.86
| Professional | | $134.90 | $229.09 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,162.28 / $3,235.94 / $3,235.94
| Professional | | $3,162.28 | $3,235.94 | $3,235.94 |