- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $478.63 / $478.63
| Facility | | $478.63 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $891.25 / $1,949.84
| Professional | | $478.63 | $891.25 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $263.03 / $2,187.76
| Facility | | $131.83 | $263.03 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $1,258.93 / $1,905.46
| Professional | | $190.55 | $1,258.93 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $104.71
| Facility | | $100.00 | $100.00 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $100.00
| Professional | | $85.11 | $85.11 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $602.56 / $1,949.84
| Facility | | $125.89 | $602.56 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $891.25 / $1,949.84
| Professional | | $478.63 | $891.25 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $125.89 / $1,318.26
| Professional | | $30.20 | $125.89 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,258.93 / $1,905.46
| Professional | | $1,258.93 | $1,258.93 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,819.70 / $1,819.70
| Professional | | $1,412.54 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $117.49 / $870.96
| Facility | | $74.13 | $117.49 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $74.13 / $812.83
| Professional | | $69.18 | $74.13 | $812.83 |