- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $5,754.40 / $12,589.25
| Facility | | $239.88 | $5,754.40 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $239.88
| Professional | | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $489.78 / $831.76
| Facility | | $239.88 | $489.78 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $407.38
| Professional | | $239.88 | $239.88 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $371.54 / $562.34
| Professional | | $323.59 | $371.54 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $588.84 / $1,000.00
| Facility | | $338.84 | $588.84 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $398.11
| Professional | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $239.88 / $323.59
| Professional | | $204.17 | $239.88 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $363.08
| Facility | | $239.88 | $239.88 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $407.38 / $602.56
| Facility | | $389.05 | $407.38 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $407.38 / $602.56
| Professional | | $389.05 | $407.38 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $295.12 / $512.86
| Facility | | $239.88 | $295.12 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $309.03 / $426.58
| Professional | | $239.88 | $309.03 | $426.58 |