- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $3,090.30 / $3,090.30
| Facility | | $331.13 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $331.13 / $3,019.95
| Professional | | $169.82 | $331.13 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $501.19 / $512.86
| Professional | | $457.09 | $501.19 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $371.54 / $588.84
| Facility | | $371.54 | $371.54 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $602.56 / $1,000.00
| Professional | | $371.54 | $602.56 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $588.84 / $2,818.38
| Facility | | $331.13 | $588.84 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $263.03 / $549.54
| Professional | | $173.78 | $263.03 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $1,412.54
| Professional | | $575.44 | $575.44 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $588.84 / $588.84
| Facility | | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,318.26 / $1,412.54
| Professional | | $724.44 | $1,318.26 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $309.03 / $602.56
| Facility | | $199.53 | $309.03 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $263.03 / $407.38
| Professional | | $190.55 | $263.03 | $407.38 |