- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $2,754.23 / $2,754.23
| Facility | | $128.82 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,754.23 / $2,754.23 / $3,235.94
| Professional | | $2,754.23 | $2,754.23 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,344.23 / $3,019.95 / $3,162.28
| Facility | | $2,344.23 | $3,019.95 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,951.21 / $3,019.95 / $3,162.28
| Professional | | $2,951.21 | $3,019.95 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $208.93 / $229.09
| Facility | | $144.54 | $208.93 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $117.49 / $630.96
| Professional | | $93.33 | $117.49 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $537.03 / $1,000.00
| Facility | | $218.78 | $537.03 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $524.81 / $588.84
| Professional | | $93.33 | $524.81 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $112.20 / $630.96
| Professional | | $107.15 | $112.20 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $208.93 / $309.03
| Facility | | $169.82 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $602.56 / $1,318.26
| Professional | | $107.15 | $602.56 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Professional | | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $112.20 / $245.47
| Facility | | $93.33 | $112.20 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $125.89 / $141.25
| Professional | | $93.33 | $125.89 | $141.25 |